Advanced Critical Care > Midterm Exam > Flashcards

Midterm Exam Flashcards

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1
Q

Capnography

A

Uses infrared light which is absorbed by CO2. The more infrared red light absorbed, the higher the values are,

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2
Q

Mainstream ETCO2 Monitor

A

The sample is taken and measured in the main stream of exhaled gas.

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3
Q

Side Stream ETCO2 monitor

A

Small sample from exhaled Vt is drawn off. Measured at the monitor not in the mainstream of gas.

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4
Q

Advantages and disadvantages of mainstream capnography

A

Pros:
- Fast response time
- Real-time readings
Cons:
- Sensor needs to be heated to reduce condensation
- Sensor is bulky and heavy
- Adds deadspace
- Does not measure nitrous oxide (N2O)

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5
Q

Advantages and disadvantages side stream capnography

A

Pros
- No bulky sensors
- Easy to use on non-intubated patients
- able to measure nitrous oxide
Cons
- Slower response time
- Needs a water trap
- Condensate or secretions may block the sampling line
- Sample flow way reduced delivered Vt

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6
Q

Using PetCO2 during CPR

A

During CA, PetCO2 can fall to zero
PetCO2 10-20 mmHg = effective CPR
PetCO2 <10 mmHg = ineffective CPR
Rapidly rising PetCO2 occurs during ROSC

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7
Q

Troubleshooting colorimetric capnometers

A
  • Gastric CO2 may be elevated after mouth to mouth resuscitation or after consuming carbonated beverages
  • There may be the presence of CO2 immediately after accidental intubation into the esophagus
  • To assess proper ETT placement, you should see rapid changes for 6 complete breaths cycles
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8
Q

Alveolar ventilation equation

A

(Vt - Vd) x f = Va

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9
Q

Anatomic deadspace

A

Amount of gas in the conducting airways from mouth/nose to terminal bronchioles
VDanat = IBW in lbs

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10
Q

VD/Vt ratio

A

Normal ratio is Vd/Vt 20-40%
Slightly higher with intubated patients
60% or greater is a contraindication to weaning
(PaCO2 - PECO2) / PaCO2 = VD/Vt

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11
Q

What are lung recruitment maneuvers (RM)?

A

Temporarily sustaining alveolar pressures to open the lungs and then setting appropriate levels of PEEP to keep the lungs open.
- Prevent derecruitment
- Is considered a lung protective strategy (improves oxygenation)

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12
Q

Indications for RM

A

ARDS
Post op atelectasis
Post suctioning for ventilated patients

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13
Q

Goals of RM

A

Improved oxygenation
Improved ventilaton (decreases dead space)
Improved compliance

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14
Q

Sustained inflation method

A

Increase CPAP 30-40cm H2O for 40 seconds with vent set on spontaneous mode

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14
Q

Contraindications for RM

A

Bullae/Blebs/Pneumothorax
Unilateral lung disease
Hemodynamic instability
Use cautiously in patients with intracranial hypertension

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15
Q

PC-CMV with high PEEP method

A

PC-CMV: set pressure to 20cmH2O with rate of 10 to 14 breaths
Then PEEP increased to 20cmH20
Hold for 40-60 seconds
then start to reduce PEEP using P/V loops

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16
Q

PC-CMV with increased PEEP

A

PC-CMV with a rate of 10 to 12 breaths
incrementally increase PEEP by 5cmH2O every 2-5 minutes while monitoring CStat
Then incrementally reduce PEEP using P/V loops until compliance is decreased (the point where cstat decreases = UIPd)
Re-inflate the lungs, then PEEP is reduced to 2-4cmH2O above the UIPd

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17
Q

Recruitment and Decremental PEEP

A

Decremental PEEP study
After lungs are fully inflated, PEEP is progressively decreased by %cm using P/V loops until compliance is decreased
Fully re-inflate the lungs, the PEEP is reduced to 2-4 cmH2O above the UIPd

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18
Q

Sigh breath methods

A

Helpful when using lower Vt (6 mL/Kg)
1. 3 consecutive sigh breaths/min at Pplat of 45 cmH2O
2. 2 x Vt with optimal PEEP set
3. Increase PEEP to 30cmH2O while decreasing Vt. Hold for one minute after each change. Then repeat
4. Increase respiratory pressure to 20 to 30 cmh2o for 1 to 3 seconds at rate of 2 to 3 sighs/min
5. APRV or HFOV

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19
Q

Invasive arterial pressure monitoring

A

Cannulation of an artery and the attachment of the catheter to high pressure, fluid filled tubing
The pressure in the tubing is converted into a digital electrical signal and displayed on an oscilloscope

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20
Q

Indications for A-Line

A
  • Need to continuously monitor arterial blood pressure
  • Need to obtain repeated arterial blood samples over several days
  • To monitor the effects of vasoactive medications
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21
Q

A-Line insertion sites

A

Radial (most common)
Brachial
Axillary
Femoral
Dorsal pedal arteries

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22
Q

Complications of arterial cannulation

A

Ischemia
Necrosis
Thrombosis
Embolism
Hemorrhage
Infection

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23
Q

Pressures measured on waveform

A

Systolic pressure = The peak of the waveform (100 to 120mmHg)
Diastolic pressure = the lowest point of the waveform (60 to 80mmHg)
Pulse pressure = Difference between systolic and diastolic pressure. Reflection of stroke volume by the left ventricle and arterial system compliance (40 mmHg)
Mean arterial pressure = average pressure during the cardiac cycle (70 to 90mmHg)
Dicrotic notch = closing of the aortic notch

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24
Calculating MAP
The heart is in diastole twice as long as systole Systolic pressure + (2x diastolic pressure) / 3
25
Factors causing hypertension
Increased volume Sympathetic stimulation Vasoconstriction Vasopressors
26
Factors causing hypotension
Hypovolemia Cardiac failure pressure Shock Sepsis leading to vasodilation
27
Troubleshooting A-Line when catheter tipis occluded by clot
Aspiration of the clot by flushing with heparinized syringe
28
Troubleshooting A-Line when catheter tip is resting on the wall of the vessel
Reposition catheter while observing waveform or use ultrasound
29
Troubleshooting A-Line when there is a clot in the transducer or stop cock
Flush system or change the stop cock and transducer
30
Troubleshooting arterial lines with abnormal high or low values
Improper calibration - Recalibrate monitor and strain gauge Improper transducer position - Keep transducer at the level of heart. If patient is lower than the transducer the values will be low, and vice versa
31
Troubleshooting A-line with no pressure reading
Improper scale selection - select appropriate scale Transducer not open to catheter - check system/stopcock to ensure transducer is open to the catheter
32
Normal NIF and FVC values
Nif > -20cmH2O VC = 65-75ml/kg under 10 is unacceptable
33
ARDS
Acute respiratory distress syndrome causing inflammation of the pulmonary capillary endothelium and alveolar epithelium results in increased permeability Produces stiff lungs causing reduced lung compliance and decreased FRC
34
Two phases of ARDS
Acute exudative phase - characterized by inflammation and alveolar filling Subacute phase - Fibrosing alveolitis occurs - If inflammation is not controlled after 8 days, fibrosis usually sets in
35
Volume support (VSV)
spontaneous mode, closed loop, no back up rate. The better the patient gets, the less work the ventilator will do - patient triggered - patient cycled - patient determines itime and rate Delivers pressure limited, volume targeted breaths - adjusts the pressure breath to breath to achieve target Vt
36
ATC, tube compensation
Spontaneous breath type - used to overcome the imposed WOB for the ETT/Trach tube - hybrid of PSV Automatically compensates for the flow-dependent pressure drop across the ETT - Set support from 10 to 100%
37
Pressure Regulated Volume Control (PRVC)
- closed loop form of PCV - target Vt and F are set. initial breath with plateau is given used to determine CLT and raw. - The CLT and raw information are then used to deliver the set target Vt at the lowest possible PIP - Pressure adjusts from breath to breath based on patient changes NOT recommended for patients with severe asthma or COPD
38
Adaptive Support Ventilation (ASV)
Similar to PRVC with the addition of volume support ventilation (VSV) if patient is spontaneously breathing, vent will deliver VS breaths (vol target pressure limited) If patient is passive, ventilator will transition to PRVC breath Targets %minvol vs Vt
39
Advantages of ASV / settings
One mode for all patients - transitions patient from control mode to spont mode breath by breath Simple settings - %minvol - FiO2 - PEEP
40
APRV indications
ARDS Atelectasis Extra thoracic states of low chest wall compliance - Chest wall edema - Burns - Abdominal distention
41
Goals of APRV
Helps alveolar recruitment Restores FRC Improves oxygenation Minimize alveolar distention Avoid RACE
42
Relative contraindications for APRV
Unmanaged increases in ICP Large bronchopleural fistulas Possibly obstructive lung disease
43
P-High when changing from PC to APRV
Set P-high same as the PIP or the same as the MAP
44
Setting P-high when going from VC to APRV
Set p-high the same as the Pplat or Pplat +2
45
Setting ventilation in APRV
Long T-high (4-6sec) results in inverse I:E Short T low - allows for CO2 removal - pressure do not return to zero due to air trapping - Release time is short to prevent loss of FRC and derecruitment
46
%trap calculation
TEFR/PEFR Goal range: 50-75% Shorten Tlow to increase %trap
47
Adjusting CO2 in APRV
Decrease T-high Increase P-high, creating a greater change in pressure (increased driving pressure) will help lower CO2
48
Correcting oxygenation in APRV
Adjust FiO2 Adjust %trap by lowering T-low
49
Weaning in APRV
Drop and stretch Drop P-high 2cm Stretch T-high 1 sec Q2
50
Normal, short, and long time constant
RCexp 0.60 sec - normal RCexp <0.19 sec for restrictive = short RCexp 1.04 sec for obstructive = long
51
%MinVol values with various diseases
ARDS= 120% COPD = 90% Others = 110%
52
Adverse side effects of too much PEEP
- Decreased venous return - Decreased CO - Decreased BP - Increased shunting - Barotrauma or Volutrauma - Increase DS ventilation - Decreased CStat w/ lung overdistention
53
Examples of Auto-PEEP
breath stacking Dynamic PEEP Air trapping Incomplete exhalation
54
Causes of Auto-PEEP
Increased expiratory resistance - bronchospasm - narrowed / kinked ETT - secretions - HME filter Loss of elastic resistance - Emphysema Inadequate expiratory time
55
Readiness to wean PEEP criteria
- Acceptable PaO2 on an FiO2 less than 0.50 - Hemodynamically stable - Non-septic - Improved lung condition
56
Flexible bronchoscopy procedure
FB can performed on: - spontaneously breathing patients via the nasal or oral route - Intubated patient on mechanical ventilation Most are performed under moderate or deep sedation - for deep sedation, the procedure is performed either via a laryngeal mask airway or an ETT
57
FB on vented patient, what parameters should be monitored?
PIP Paw ETCO2 SaO2
58
Therapeutic indications for FB
- Aid in difficult intubation - Foreign body aspiration - Wheezes and stridor upper airway obstruction - Aid in dilating airway or placing stents
59
Diagnostic indications for FB
- Biopsy carcinoma/tumors - Investigate cause of hemoptysis, unexplained cough or wheeze - Examine vocal chords and patency of airway - Sputum sample for infiltrates
60
Absolute contraindications for FB
- Uncorrectable hypoxemia - Lack of patient cooperation - Lack of skilled personnel - Unstable angina - Uncontrolled arrhythmias
61
Relative contraindications to FB
- Unexplained or severe hypercarbia - Uncontrolled asthma attack - Uncorrected coagulopathy - Recent MI - Unstable cervical spine
62
Indications for Rigid bronchoscope (RB)
- Bleeding or hemorrhage - Foreign body extraction / airway obstruction - Dilation of tracheal or bronchial strictures - Insertion of stents - Tracheobronchial laser therapy - Mechanical tumor ablation
63
Absolute contraindications for RB
- Absence of signed consent - Unstable angina or hemodynamic status - Coagulopathy or uncontrolled breathing - Severe obstructive airway disease
64
Relative contraindications for RB
- Lack of patient cooperation - Moderate to severe hypoxemia or hypercapnia - Lung abscess - Recent MI - Unstable cervical spine - Partial tracheal obstruction
65
Hazards of FB or RB
Bleeding Infection Pneumothorax Bronchospasm Hypoxemia Cardiac arrythmias, heart attack, or stroke
66
Cause and management for bleeding during FB
Cause: Biopsy instruments or patients with clotting issues Tx: Instill epinephrine (or iced saline) hold blood thinners before procedure
67
Cause and management of Infection during FB
Cause: Contamination during procedure Management: Use sterile technique and monitor patient post procedure
68
Cause and management of pneumothorax from FB
Cause: puncture from biopsy Tx: Pt will have sudden chest and SOB. Tx ranges from CXR, increasing O2, chest tube or needle decompression
69
Cause and management of bronchospasm
Cause: Irritation from procedures Management: Increase FiO2 and administer bronchodilator
70
Cause and management of hypoxemia during FB
Cause: Bronch obstructing airway, too much sedation possibly Tx: Increase FiO2 and adjust sedation
71
Cause and management of Cardiac instability during FB
Cause: Hypoxemia Management: Keep SpO2 levels within range, be aware of underlying comorbidities
72
Endobronchial ultrasound (EBUS)
- EBUS has improved the accuracy of TBNA - Uses linear ultrasound probe attached to distal end
73
Electromagnetic navigational bronchoscopy (ENB)
- Help reach peripheral tumors outside the reach of standard bronchoscope - uses low frequency electromagnetic waves transmitted from a magnetic board place below patient's chest - Bronchial dye is used to aid in visualization of tumors
74
Bronchial Thermoplasty
- Tx for steroid dependent asthma - Reduces bronchial smooth muscle thickness - Takes several treatments - Applies controlled heat to reduce smooth muscle
Advanced Critical Care
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