Critical Care Test 1 > Mechanical Ventilation lectutre > Flashcards

Mechanical Ventilation lectutre Flashcards

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1
Q

Tidal volume (vt)

A

amount of air inhaled and exhaled

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2
Q

Inspiratory Reserve volume (IRS)

A

maximum air inhaled over tidal volume

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3
Q

Expiratory Reserve Volume (ERV)

A

max amount of air exhaled over Tidal volume

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4
Q

Residual volume (RV)

A

amount of air left in lung after exhale

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5
Q

Functional Residual Capacity

A

SUM of ERV and Vt

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6
Q

Oropharyngeal Airway:

-location

A
  • follows natural curvature of the tongue

- holds tongue away from throat to maintain patency

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7
Q

Oropharyngeal Airway:

-what types of patient to use it on

A

UNCONSCIOUS patient who has an absent or diminished gag reflex

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8
Q

Oropharyngeal Airway:

-what are the benefits? complications that it avoids?

A

Avoids the risk of nasal irritation and sinitus

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9
Q

Nasopharyngeal Airway:

-location

A
  • inserted into one nare

- maintains patency of hypopharynx

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10
Q

Nasopharyngeal Airway:

- what does it limit the stimulation of?

A

gag reflex

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11
Q

Tracheostomy:

-what type of patients to use it on?

A

-LONG TERM MANAGEMENT: 7-10 days

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12
Q

Tracheostomy:

-advantages of having a trach for the patient

A
  • more comfortable for the patient
  • patient can eat and talk
  • easier to remove secretions
  • reduces decannulation
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13
Q

Tracheostomy:

-two ways to insert the trach

A

1) OR surgical

2) percutaneous procedure- bedside

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14
Q

Tracheostomy:

-two items to have at the bedside for safety

A
  • obturator
  • 2nd trach + a smaller size for accidental dislodgement
  • vaseline gauze
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15
Q

Tracheostomy:

-complications during insertion

A
  • misplacing the tube
  • hemorrhage
  • laryngeal nerve injury
  • pneumothorax
  • cardiac arrest
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16
Q

Tracheostomy:

-complications in management

A
  • stomal infection
  • hemorrhage
  • fistula
  • tube obstruction and displacement
  • *SKIN BREAKDOWN!
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17
Q

Tracheostomy:

-complications with removal

A
  • days to weeks after:

- stenosis and fistulas

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18
Q

Tracheostomy:

-when should sutures be removed?

A

-only in there for 7-10 days

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19
Q

Endotracheal Tubes:

-location

A
  • insertion into the trachea via the nose or mouth
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20
Q

Endotracheal tubes:

-what type of patients to use it on

A

SHORT TERM management

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21
Q

Endotracheal Tube:

-Indications for use

A
  • protection from aspiration
  • application of positive pressure ventiation
  • high oxygen concentrations
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22
Q

Endotracheal Tube:

-what happens if the air-filled cuff deflates?

A

-risk for aspiration pneumonia

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23
Q

Endotracheal Tubes:

-advantages of use for healthcare professionals

A

First.
Fast.
Easiest

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24
Q

Endotracheal Tubes:

- complications

A
  • ORAL TRAUMA: broken teeth
  • vomiting with aspiration
  • hypoxemia
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25
standard intubation equipment
- laryngoscope - oral Endotracheal tube with various sizes - ambu-bag and O2 - suction equip - paralytic meds - cap CO2 detector- turns purple to yellow
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Rapid Sequence Intubation -7 steps (1-4)
1) preperation 2) Pre-oxygenate for 3-5 min with 100% 3) Pretreatment within 3 min of next step 4) give paralytics and sedatives
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Rapid Sequence Intubation (RSI) 1) paralytics 2) sedatives
1) succinylcholine and rocuronium | 2) Versed, ketamine
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Rapid Sequence Intubation (RSI) | -step 5
5) Protection and Positioning - Sniff position - Sellick maneuver (cricoid pressure) - BURP
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RSI: - Sniff position - Cricoid pressure
- tilt back with neck hyperextended - BURP: back, up, right, pressure on trachea * closes off risk for aspiration
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Rapid Sequence Intubation (RSI): | -stepts 6-7
6) Placement of ETT (3-4 cm above carina) - intubate less than 30 sec, if not, re-oxygenate 7) Post intubation management
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Aspiration of as little as ____ mL of gastric content may result in significant injury to the patient
20
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Prevention of Endotracheal Tube complications: | -tube obstruction
- bite block - humidify - replace old ETT's
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Prevention of Endotracheal Tube complications | -Tube displacement
- secure tube - restraints - sedate
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Prevention of Endotracheal Tube complications | - Sinusitis and nasal injury
- Avoid nasal intubations | - antibiotics
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Artificial Airway Cuffs- | -purpose
- small balloon inflated to prevent leakage of inhaled air past the tube into the upper airway - CLOSED SYSTEM
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Artificial Airway Cuffs- | -Minimal Leak technique
-place stethescope over larynx and inject 0.5 ml of air into the cuff at a time until small inspiratory leak is auscultated
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Artificial Airway Cuffs- | -Minimal Occluding Pressure
inflate then decrease by 0.2 ml. when you hear an air leak increase to the point air leaks and trachea is sealed "darth vadar " noise
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how to suction a patient?
- give 3 100% breaths | - do not suction for more than 10-15 seconds
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What to do if ET tube pulled out?
- page doctor - listen to lungs sounds - call RT
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what is mechanical ventilation
any means in which physical devices or machines are used to either assist or replace spontaneous respirations
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Indications for mechanical ventilation
- relieve upper airway obstruction - Acute lung failure - PaO2
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What must you give the patient when on Mechanical Ventilation
- sedation | - neuromusclular blockade
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Mechanical Ventilation: | -Negative-Pressure ventilators
- "iron lung" - applied externally to patient - ** decreases atmospheric pressure surrounding the thorax to initiate inspiration
44
Mechanical Ventilation: | -Positive Pressure Ventilators: (PPV)
-forces gas into the lungs to expand them
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Mechanical Ventilation: | -Positive Pressure Ventilators: (PPV) 2 types
1) Volume cycled | 2) Pressure cycled
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Positive pressure ventilators: | 1) VOLUME CYCLED
- gas flows into lungs until a preset VOLUME of gas has been delivered - constant tidal volume regardless of compliance and airway resistance
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Positive pressure Ventilators: | 2) PRESSURE CYCLED
- gas flows into the lungs until a preset PRESSURE is reached - delivery of desired tidal volume is NOT guarenteed
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Mechanical Vent. Settings | -Trigger
-what causes the vent to deliver breath (pressure or flow)
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Mechanical Vent. Settings | -Sensitivity
determines the amount of effort patient must generate before the ventilator will deliver a breath
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Mechanical Vent. Settings - Sensitivity: - if setting TOO LOW - if setting TOO HIGH
- pt works harder to breath | - asynchronus breathing
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Mechanical Vent. Settings | -Respiratory rate
-6-20 * key way to control CO2 adjust according to PaCO2
52
Mechanical Vent. Settings | -Tidal volume
-volume delivered per ventilator breath -500-800 mL N (6-10 ml/kg/IDB) ARDS (4-8)
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Mechanical Vent. Settings | -fraction of inspired O2 (FiO2)
% of air that is being delivered by ventilator each breath 21-100% *must maintain PaO2 80-100 and SaO2 >90
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Mechanical Vent. Settings | -Positive end expiratory pressure (PEEP)
- prevents shunt - keeps alveoli open to promote gas exchange - AFTER EXPIRATION
55
PEEP normal value
3-5 | ARDS: 5-20
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Mechanical Vent. Settings | -Flow rate
determines how fast tidal volume will be delivered
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Flow rate: - LOW - HIGH
- allows long inspiration | - allows fast inhalation for longer exhalation
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What type of flow rate does COPD want?
HIGH FLOW RATE
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Mechanical Vent. Settings | -I:E ratio
duration of inspiration to expiration | 1:2
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Mechanical Vent. Settings | -Pressure Limits
-regulate maximum amount of pressure the ventilator will generate to deliver preset tidal volume
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Positive End Expiratory Pressure | -functions
- Maintain airway pressure - Increases FRC - improves oxygenation by opening collapsed alveoli at end of expiration - decreases FiO2 to less toxic
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minute volume (MV)
total volume of gas inhaled or exhaled over 1 minure
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Peak Inspiratory Pressure PIP
airway pressure at maximum inspiration | -AIRWAY PROBLEM : mucus plug
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Plateau pressure
Pressure applied to small airways and alveoli during PPV - Measured during an inspiration pause on the mechanical ventilator * LUNG COMPLIANCE
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Modes of Ventilation: | -continuous mandatory volume (CMV) aka Assist control (AC)
-delivers gas at a preset volume or pressure -patient CAN either trigger the ventilator or machine will give a breath on its own -
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CMV/AC - advantages - disadvantages - indications
- guarentees a minimum minute ventilation - can lead to RESP ALKALOSIS and Hypotension - pts who need full ventilator support and need a steady vt
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Example of a Ventilator Mode: | -AC 16 (BUR)
Back Up Rate | -if patient unable to trigger breathing
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Modes of Ventilation: | - Synchronized Intermittent Mandatory Ventilation (SIMV)
- a mix of MANDATORY breaths and ASSISTED breaths - delivers preset volume or pressure while allowing pt to breath spontaneously - "works out lungs"
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Difference between SIMV and AC
-SIMV allows patient to breath without any support when they want to, AC allows support by ventilator
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SIMV - advantages - disadvantages - Indications
- guarentees minimun minute ventilation. Lower pressure than AC - Increased WOB for patient-fatigue - needed for patients who are hyperventilating or have high airway resistance
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REVIEW AC and SIMV
AC- receive full support | SIMV- receive partial support
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Modes of ventilation: | Pressure control ventilation (PCV)
- MANDATORY breaths only | - patient CANT trigger ventilator
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Pressure Control Ventilation (PCV) - advantages - Disadvantages - Indications
- prevents excess airway pressure, avoids alveolar over-distention, leads to earlier weaning - uncomfortable, requires DEEP SEDATION - Pts with high risk barotrauma
74
Modes of Ventilation: | - Pressure support ventilation (PSV)
- No mandatory breaths - preset positive pressure on patients inspiratory efforts - patient controls rate, flow, and vt * * Pt has control of breaths!
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Pressure support ventilation (PSV) - adavantages - disadvantages - indications
- supports breathing and helps patients with a stable respiratory drive to overcome increased airway resistance, reduces their work of breathing - apnea alarm is only back up - assist spontaneous breaths in SIMV or helps weaning
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neuromuscular blockade
paralysis of a patient using drugs that paralyze skeletal muscle but don't affect cardiac or smooth muscle
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Uses of neuromuscular blockades
- aids in intubation - acts by competing with ACh - stops muscles from depolarizing
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what must you give when you give a neuromuscular blockade?
* pt is paralyzed but fully CONSCIOUS - GIVE SEDATIVE and PAIN control - versed as an IV drip
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Neuromuscular Blockade Nursing considerations
- patent airway -ambu bag ABGs -position change and passive ROM -Protect eyes with lubricant and eye-pads
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``` Train of 4: 4/4 3/4 2/4 1/4 0/4 ```
- less than 75% -75% -80% DESIRED -90% 100%
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Troubleshooting alarms | DOPE
D- disconnections O- obstructions P-pressure/pneumothorax (check lung sounds and chest Xray) E- equipment
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why would an alarm say low pressure?
- patient disconnection - tubing disconnection - cuff leak
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why would an alarm say high pressure?
- patient coughing - secretions or mucus in airway - patient fighting the ventilator - increased airway resistance - reduced lung compliance - water in circuit - kinking in the circuit - problems with I/E valves
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why would patient be agitated or in dis-synchrony on the ventilator ?
- secondary to overall discomfort-->increase their sedation - secondary to air hunger-->adjust respiratory settings (vt, flow rate, ect) -
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complications of mechanical ventilators
- oral and dental damage - nasal damage - decrease in C.O - barotrauma/voltrauma - emphysema - infection - increase WOB
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Barotrauma/Volutrauma
- alveolar overdistention with resiliant alveolar rupture and air leak
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effect of mechanical ventilation on renal system
decreased urinary output d/t low perfusion to kidneys | * tell Dr if
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Effect of mechanical ventilation on GI?
- stress ulcers | - give pepcid
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When to draw ABGs when on a mechanical ventilator
- 30-60 min after ventilations begin | * DO NOT SUCTION for 15 min before drawing ABGs. alters O2 values
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what else should be checked besides ABG's
- Hgb | * ensure the absence of anemia and adequate perfusion
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*** what to do if: | INCREASED PaCO2
INCREASE rate or tidal volume
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*** what to do if: | DECREASED PaCO2
DECREASE rate or tidal volume
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*** what to do if: | INCREASED PaO2
DECREASE FiO2 or PEEP
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*** what to do if: | DECREASED PaO2
INCREASE FiO2
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Process of Weaning: | WEANING
``` W-WOB E- electrolytes A- attitude N-nutrition I-infection N-nonspecifc G-gases ``` * * make sure to educate the patient * * only do spont. breathing trial for 30-120 min
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weaning methods | 1) SIMV weaning
- gradual transition from vent to spontaneous breathing
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weaning methods: | 2) PSV weaning
PS mode at a level that achieves spontaneous vt | -augments pt breathing with a + pressure boost during inspiration
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ACUTE LUNG FAILURE
inability of lungs to maintain adequate oxygenation of the blood with or without impairment or CO2 elimination
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Acute Lung Failure: | Type 1
low PaO2 (
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Acute Lung Failure: | type 2
low PaO2 (45)
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Acute Lung Failure management
- O2 >90% - PaO2 45?? - ventilation: pH
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Acute Respiratory Distress Syndrome (ARDS)
non-cardiogenic pulmonary edema | -alteration of the alveolar capillary membrane
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ARDS causes: | DIRECT
- aspirate gastric content - pneumonia - near drowning
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ARDS causes: | INDIRECT
- sepsis - trauma - pancreatitis - blood transfusions - DIC
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ARDS pathophysiology:
injury occurs--> inflammatory response--> immune system releases protein mediators--> this increase the permeability of alveolocapillary membrane--> allows large molecules to enter--> collapse of the alveoli and makes lungs less compliant (stiff)
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ARDS progression: | 1) Exudative phase
- release of INFLAMMATORY MEDIATORS - within 72 hrs of injury - alveolar edema and Type 1 epithelial cells (flooding) - Xray changes in 24 hrs - mediators cause damage to alveolar hypoventilation, V/Q prob, intrapulmonary shunting, hypoxemia
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ARDS progression: | 2) Fibropolierative phase
- HEALING begins - granulation and collagen deposits - fibrotic alveoli - scarred pulmonary capillaries
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ARDS progression: | 3) Resolution phase
- REMODELING - alveolar fluid goes to interstitium - Type 2 epithelial cells multiply
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ARDS S/S
- within 48 hrs - restlessness - HTN - tachycardia - SOB - accessory muscle use - lung sounds: clear, crackles, or rales
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ARDS diagnostic findings | -ABGs
- low PaO2 | hypoxemia: PaO2/FiO2 less than 200
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ARDS diagnostic findings: | -CXR
"white out"
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ARDS diagnostic findings: | -PA cathater
PAOP
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ARDS Treatment:
-establish airway -HIGH PEEP!! keep alveolar open -sedate -A-line to maintain BP corticosteroids to help with membrane permeability -nutrition: TPN PRON POSITION
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symptoms of respiratory distress associated with ARDS begin within __ hours of insults to lungs
24-48 hrs
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what is happening at the cellular level to cause hypoxia in ARDS
leaking of alveolocapillary membranes
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high levels of PEEP can cause what ?
Decreased C.O because high intrathoracic pressure
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ARDS POSITIONING txt
* preferential blood flow occurs to the gravity-dependent areas of the lungs * positioning is used to place the least damaged portion of the lungs into a dependent position - prone - rotation
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ARDS positioning: | 1) Prone
-improves oxygenation
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ARDS positioning: | 2) Rotation
-keep them on special beds 24-48 hrs
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What would you do first to increase oxygenation in an attempt to decrease FiO2 when in oxygen toxicity?
Increase PEEP
121
Inadequate PEEP can increase the risk of:
Atelectrauma: open/close can cause alveolar damage.
Critical Care Test 1
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