Question Answer
Define Hypoxemic Respiratory Failure. the inability to maintain norm oxygen in art blood: P/F ratio<300; PaO2<60mmHg w/supp O2
Pt receives NPPV for hypoxemic resp failure, w/o improv how long should wait to intubate? No more than 1-2 hours. If pt declines w/in first 30 mins, don’t wait.
What 3 conditions are associated w/hypoxemic resp fail qualify NPPV as 1st Line therapy? 1)immunocompromised 2) awaiting transplantation 3)post lung resection
Name 3 other indications for the use of NIV therapy in acute care 1)DNI orders 2)Facilitate weaning for COPD & CHF 3)Post-opt in abdominal surgeries
Name 5 Restrictive Thoracic Diseases (RTD) for which NPPV is used in chronic care Post polio;chest wall deform.;spinal injuries;severe kyphoscholeiosis;NMD
What are 3 benefits gained by NPPV in Restrictive Thoracic Diseases 1)Improved lung compliance,volume/FRC,dead space 2)Rest muscles of insp 3)lower PaCO2
Name 6 predictors of successful NPPV use in the acute care setting 1)low severity illness 2)Resp Acid PCO2 45-92 3)pH 7.22-7.35 4)min air leak 5)rapid improved gas x-change (30min-2hrs) 6)improved RR & HR
What 3 types of ventilators are used for NPPV Non-invasive Ventilator;Critical Care Ventilator;Portable Volume Ventilator
Name 4 disadvantages of full face mask vs. nasal mask 1)increased dead space 2)risk of aspiration 3)claustrophobia 4)diff communic./expectorate
What % of acute respiratory failure patients should start w/ full face mask? 90%
Name the 5 patient Interfaces used w/NPPV Nasal mask,full face mask,mouth pc,total face mask,nasal pillows,helmet
Name the selection criteria for NPPV in care of Acute Respiratory Failure 2+ present: Paradoxical breath;access muscle use;RR>25;dyspnea;PaCO2>45;pH<7.35;P/F<200
Name the exclusion criteria for NPPV in care of Acute Respiratory Failure copious secretions;hemodynamic instability; apnea;face burns/trauma;abnor anat;uncooperativ
Name the 4 ways NIV can be provided Negative Pressure Ventilator;Positive Pressure Ventilator;Rocking Bed; Pneumobelt
How is NPPV typically administered? Nasal or oral/nasal mask
What condition must be present to add NPPV therapy with CPAP in Acute Pulm Edema? Hypercarbia (ventilatory failure)
Name the 3 “constant” end expiratory pressures that support oxygenation (all mean same thing) CPAP, EPAP, PEEP
What is the 1st line therapy for Acute Pulmonary Edema? CPAP 8-12 cmH2O w/ 100% oxygen
What is the standard of care in patients w/ acute COPD exacerbations? NPPV (as an alternative to intubation & conventional mechanical ventilation)
Name the 5 goals of NPPV in the chronic care setting 1)avoid hospital 2)increase survival 3)relieve symptoms 4)improve mobility 5)enhance life
What is the application of positive pressure w/o intubation to augment alveolar ventilation Non-invasive Positive Pressure Ventilation aka: NPPV, NIPPV, NIV
what is a rubber bladder strapped around the abdomen, when inflated assists w/ inp & exp Pneumobelt
What is the device that rocks from Trendel-enburg position to reverse to aid breath Rocking Bed
Which mode of ventilation re-establishes FRC and recruits alveoli? EPAP (or CPAP or PEEP)
what 5 nocturnal hypoventilation signs must be seen for NPPV therapy to be considered w/RTD? cognitive dysfunction;headache;fatigue; dyspnea; daytime hypersomnolence
NPPV for pt w/ severe COPD & signs of nocturnal hypoventilation must also have (3): 1)PaCO2>55mmHg 2)PaCO2 50-54mmHg PLUS noc-turnal desaturat 3)2+ hosp for ventilatorfail
When IPAP is increased… …Tidal Volume increase, Ventilation increases, and PaCO2 decreases
When EPAP is increased.. . …Tidal Volume decreases, PaO2 increases, and FRC increases
When rate control is increased… …Minute Volume increases, PaCO2 decreases

Egan’s Chapter 45 Practice Questions:

1. A 21-year-old men who suffered a C4-5 subluxation injury to the spinal cord needs ventilatory support at night. The patient has skin breakdown at the bridge of his nose. Which of the following interfaces would you select?

A nasal mask

B nasal mask that is one size larger than normal

C nasal pillows

D full face mask

2. A 57-year-old woman with a 45 pack-year smoking history and a barrel chest arrives in the emergency department complaining of shortness of breath. She is using pursed-lip breathing. Her arterial blood gas on a 2L/min nasal cannula is pH = 7.26 , PaCO2=64mmHg, PaO2=50mmHg, and HCO3=36mEq/L. Which of the following ventilators would you select?

A intubate and use a critical care ventilator

B noninvasive ventilator

C critical care ventilator

D portable volume ventilator

3. A 67-year-old man had a surgical repair for a perforated gallbladder with peritonitis one week ago. He was extubated earlier in the day, but he presently has a respiratory rate of 32 breaths/min, is diaphoretic, and is using accessory muscles to breath. His ABGS on 60% O2 aerosol is pH= 7.40 PaCO2= 31mmHg PaO2= 71mmHg and HCO3= 19mEq/L. Which of the following action is most appropriate?

A use only CPAP to improve oxygenation

B use a noninvasive ventilator

C intubate the patient if there is not significant improvement within 1 to 2 hours

D use a nasal mask to decrease risk of claustrophobia

4. After Mr. Pierre adjusts to the initial feel of NPPV, which of the following settings would you like to achieve?

A IPAP= 14cm H2o, EPAP= 8cm H2O FiO2= 0.60

B IPAP= 8cm H2O, EPAP= 4cm H2O FiO2= 0.40

C IPAP= 10cm H2O, EPAP= 8cm H2O FiO2= 0.50

D IPAP= 8cm H2O, EPAP= 6cm H2O FiO2= 0.40

5. After Mr. Pierre is breathing for 10 minutes on his new NPPV settings, you see the following image on his ventilator graphics. Which of the following changes would you make?

A increase the IPAP by 2cm H2O

B adjust the trigger sensitivity

C adjust the termination of flow

D no changes are necessary

6. All of the following types of patients could benefit from noninvasive positive-pressure ventilation except:

A ARDS

B COPD

C neuromuscular weakness

D weaning from mechanical ventilation

7. Mr. Pierre has been on his NPPV for the past 2 hours. His respiratory rate is 26 breaths/ min with moderate accessory muscle use. After viewing his arterial blood gas values on FiO2= 0.50, which of the following would you recommend?

A maintain current setting

B increase IPAP by 2cm H2O

C increase the FiO2 to 0.60

D reintubate and use invasive ventilation

8. Noninvasive CPAP is indicated for which of the following?

A hypercarbia respiratory failure

B hypodermic respiratory failure

C acute cardiogenic pulmonary edema with hypoxemia only

D postpolio syndrome

9. The physician recommends a trial of noninvasive ventilation before reintubation. Which of the following ventilators would you plan to use?

A noninvasive ventilator

B critical care ventilator

C portable volume ventilator

10. Where would you set the initial IPAP and EPAP levels as you help Mr. Pierre adjust to the NPPV?

A IPAP= 12cm H2O, EPAP= 8cm H2O

B IPAP= 10cm H2O, EPAP= 6cm H2O

C IPAP= 4cm H2O, EPAP= 2cm H2O

D IPAP= 8cn H2O, EPAP= 4cm H2O

11. Which of the following actions will improve patient synchrony during NPPV?

A change the interface to reduce leaks

B increase the time-cycle to 1.2s

C initiate volume-controlled ventilation

D coach the patient to inhale more deeply

12. Which of the following best describes the type of respiratory problem Mr. Pierre is likely experiencing?

A hypoxemia respiratory failure

B hypercarbic respiratory failure

13. Which of the following practices would help your patient adjust to NPPV best?

A use a nasal mask so that the patient can easily communicate

B select a high IPAP setting to immediately help the patient catch her breath

C strap the mask securely in place to prevent air leaks

D hold the mask in place with your hands until the patient adjusts to the gas flow

14. Which of the following statements about noninvasive ventilators is true?

A the ventilators will not function properly if a leak is present

B the ventilators have an external exhalation valve

C the inner lumen of the circuit must be completely smooth

D rebreathing carbon dioxide may occur at high EPAP levels: The inner lumen of the circuit must be completely smooth

15. Which of the following statements about noninvasive ventilatory support is true?

A The negative pressure change causes exhalation with negative pressure ventilation

B inflating the bladder on the pneumobelt promotes inhalation of gas into the patient’s lungs

C rocking into trendelenburg position causes inspiration with a rocking bed

D the positive pressure in noninvasive positive-pressure ventilation inflates the patient’s lungs

16. Which statement related to improving patient comfort with NPPV is correct?

A heated humidification should be added to all NPPV breathing circuits

B a rise in pressure at the end of inspiration in a pressure-controlled breath indicates an increased work of breathing

C all critical care ventilators can adjust for leaks as well as noninvasive ventilators

D nasal mask work equally as well as full face mask

17. Which type of interface would you select for Mr. Pierre?

A nasal pillows

B total face mask

C full face mask

D nasal mask

18. How is Noninvasive ventilation abbreviated for this class?: NIV

19. NIV use has increased due to what?: improved patient interfaces, Improved quality of NIV ventilators, NIV software available for critical care ventilators, Reports of success in literature

20. Normal PF Ratios/indications: Normal: 500, <300 NIV, <200 ARDS

21. NVI indicated for physical diseases??? SAY WHAT?: Post polio, NMD, chest wall deformities, spinal injuries and severe kyphoscoliosis can benefit from NVI. (helps to rest breathing muscles, lowering CO2 & Deadspace and increasing Compliance and FRC.

22. something about a byrd machine: Something important here.

23. What are key attributes to the pneumobelt?: rubber bladder strapped to abdomen then when filled compresses abdominal contents pushing up on the diaphragm causing exhalation. Bladder deflation causes diaphragm to fall and cause inhalation.

24. What are key points of NIV?: Supports ventilation without artificial airway, earliest example being bag-mask.

25. What does NIV encompass?: Ventilation and CPAP, typically provided by nasal or oral mask.

26. What is a chest cuirass:: Therapeutic Godzilla Hickey

27. What is an example of a Negative-Pressure ventilator?: Iron Lung

28. What is IPAP-EPAP?: Pressure support

29. What is the primary indication for noninvasive ventilation?: Hypercapnic respiratory failure due to COPD. (Standard of care for managing an acute exacerbation of COPD *FIRST LINE THERAPY*)

30. What other conditions benefit from NIV?:  Asthma, Acute cardiogenic pulmonary edema, Hypoxemic respiratory failure

31. What other patients should NVI be considered for?: DNI (Do not intubate) patients, Postoperative patients, patients in need of weaning facilitation (CHF and COPD patients). Nocturnal hypoventilation

32. Why use NIV for Hypercapnic respiratory failure due to COPD?: Strong evidence in reducing the need for intubation, Hosp mortality and length of stay.

33. Chest Cuirass: A device to deliver negative pressure ventilation that only fits over the thorax.

34. hypoxemic respiratory failure: The inability to maintain the normal oxygenation in the arterial blood. It may be indicated by a PaO2 of less that 60 mm Hg in individual breathing supplemental oxygen.

35. Inspiratory Positive Airway Pressure (IPAP): Pressure that is applied during the inspiratory phase of mechanically assisted ventilation.

36. Iron Lung: A full body negative pressure ventilator.

37. negative-pressure ventilator: An approach to ventilation in which negative pressure is intermittently applied to the chest surface in an effort to cause inflation of the lungs.

38. nocturnal hypoventilation: Nocturnal Hypoventilation Syndrome is related to sleep apnea, but is due to the brain’s respiratory control center not sending out enough nerve impulses to the breathing muscles. So, rather than the breathing being stopped by obstruction to the upper airways behind the tongue (as with OSA), there simply is not enough breathing and sometimes complete cessation of breathing.

39. noninvasive positive pressure ventilation (NPPV): A positive-pressure ventilation without endotracheal intubation or tracheotomy, usually via a form-fitting nasal mask.

40. pneumobelt: A ventilatory assist device that applies positive pressure to the abdominal contents during expiration.

41. Rocking bed: A bed that rocks back and forth moving the abdominal contents up and down facilitating inspiration and expiration.

42. Trendelenburg position: A position in which the head is low and the body and legs are on an inclined plane