Question Answer
Initiating mechanical vent: What mode do you choose? doesnt matter as long as you can set RR
Name 2 Full Support Modes in which you can set RR Controlled Mandatory Ventilation(CMV), Assist control (A/C)
Name 2 Partial Support modes in which you can set RR Intermitetnt Mandatory Ventilation(IMV), Synchronized intermittent mandatory ventilation(SIMV)
Name 1 little to no support mode CPAP
What 2 options on the vent allow you to manage CO2? RR and Vt
What is the initial setting of RR for a new mechanical vent patient? 8-12 breaths per minute
What is the initial setting for VT for a new mechanical vent patient? 8-12 ml/kg IBW
Spontaneous Vt is driven by ___ ____ and not considered on initiation of mechanical vent pressure support
What 2 options on the vent allow you to manage O2 (SaO2)? FiO2 and PEEP
What is the initial FiO2 setting for mechanical vent? 40% or 100%
Which patients FiO2 should be set at 40% on initiation? non-cardiopulmonary issues
Which patients should be started at 100% on initiation? patients with cardiopulmonary issues
What is the FiO2 exception rule? pt with a known FiO2 on different device (i.e. CPAP or BiPap) should be kept on that FiO2 when put on mechanical vent
What is the initial PEEP setting on mechanical vent? 5-10 cmH2o
All patients being set up on mechanical ventilation must have what done? ABG within 30 minutes of being placed on vent
What should the VT alarm be set at? +/- 100ml exhaled Vt or +/- 10% exhaled Vt
What should the RR alarm be set at? 10-15 bpm above observed
What should the minute ventilation alarm be set at? >10LPM or +/- 1L exhaled VE
What should PIP alarmn be set at? +/- 10-15cwp, but never greater than 50cmH2o
What should Plat alarm be set at? + 10, but never greater than 35cmH2o
If PIP and/or Plat are extrememly low, what could be the cause? leak
High PIP indicates what? Increased Raw
High Plat indicates what? increased Cs
Indications for Mechanical Ventilation includE: Apnea, Acute ventilatory failure, Impending respiratory failure, severe hypoxemia, surgery, prophylactic support for pulm complications
What constitutes acute ventilatory failure? pt contain sustain spontaneous ventilation to provide adequate oxygenation and ventilation, pH<7.25, PaCO2 >50; COPD(decomp resp acidosis with PaCO2 above pt norm)
NIF or MIP < __ cmH2o, intubate 20cmH2o
Criteria for impending Respiratory failure: Vt< 5cc/kg IBW, VC< 10cc/kg IBW, RR>35 or <10, VE> 10LPM, NIF<-20cwp,RSBI>105
What is an absolute contraindication for mechanical vent untreated tension pneumo
What is %Ti Percentage inspiratory time (ex- 1:2=3, 1/3=33%)
What mode of ventilation is used in patients with ARDS? pressure controlled ventilation
Indications for PCV are: PIP>50, Plat>35, PEEP>15,FiO2 100%, Assist control rate 16/min
What are the initial settings for PCV? FiO2 100%, pressure set at or above Pplat, Vt 6-10ml/kg IBW, I:E 1:2
Why would you initially set tidal volumes lower than 8-12ml/kg IBW? low compliance(ARDS 6-8ml/kg), Increased compliance, air trapping; or need for reduced lung volumes (pneumonectomy)
What can cause Exhaled Vt to be higher that delivered Vt? circuit compressible volume loss
Greater circuit compliance = greater volume lost per unit pressure
Volume lost is not delivered to patient but is what recorded in exhaled volume measurement (some measure vol at AO, some automatically compensate for compressible vol loss)
Volume lost = compression factor x PIP
Corrected Vt = Set Vt- Vt lost
Compressible volume loss is usually only significant in which patients? neonatal and pediatric d/t low volumes used
What type of ventilation only supports spontaneous breathing and is not needed during initial setting of vent? Pressure support ventilation
PSV pressure is set to deliver how much volume? 5-7ml/kg IBW of spontaneous Vt
Estimated VE formula male 4 x BSA; female 3.5 x BSA
BSA formula [(4 x kg) + 7]/(kg + 90)
desired RR= estimated VE/ desired Vt
What 2 things must you monitor when using PEEP? BP and ABG
Why would you increase PEEP? refractory hypoxemia, FiO2 > 60%
What is the most common method of I:E change? changing the flowrate
Increasing flow rate= decrease Ti, increase Te, increase I:E
Decreasing flow rate= increase Ti, decrease Te, decrease I:E
Normal flow rate = 40-60LPM
Ti x Flowrate= Vt
Why is Longer I time 1:1, IRV is used correct refractory hypoxemia, create auto-PEEP, decrease in compliance
Changes in RR affect the length of what? exhalation
What type of flow pattern would you see with IPPB? square
This type of flow pattern enhances gas distribution for patients with airway obstruction but may cause asynchrony? Accelerating
This type of flow pattern creates high PIP and satisfies patient flow demand? Decelerating
This is the most natural type pf flow pattern similar to spontaneous breathing? Sine
Apnea alarm setting is 15-20 second delay
FiO2 alarm set at +/- 5% set FiO2
Complications of mechanical vent include Barotrauma/Volutrauma, decrease in CO, BP; pulmonary infection, Tracheal damage, decreasedUO, resp muscle fatigue, poor nutrition
PIP>50, MAP>30, Pplat>35, PEEP>10 can all cause barotrauma/volutrauma
Question Answer
What are the 4 methods to take for a full ventilatory support? 1. Initiating Mechanical ventilation 2. Maintenance of Mechanical Ventilation 3. Discontinuing/Weaning Mechanical Ventilation 4. General Considerations in Mech. Ventilation(Pharmacology&Positioning)
What are the indications of initial Mechanical Ventilation? 1.Acute vent. Failure (PaCO2,pH) 2 Observed cessation of breathing (Apnea) 3Impending vent. Failure – a. Determined by serial ABG’s. b. Shows a degradtion of vent.(climbing PaCO2 & decreasing pH)C.DO not wait until vent. Failure -look for a downward trend
What causes Mechanical Ventilation Failure? 1. MIP < -20 cmH2O. 2. RR < 8. 3. Ve – < 10 L/min. 4. VC < 10 mL/Kg. 5. Vt < 5 mL/Kg. 6. MEP < 40 cmH2O. 7. VD/VT – > 60%. 8. QS/QT – >20%
What are the other data that may collectively indicate need for Mechanical Ventilation? 1. No chest movement. 2. Absent breath sounds. 3. Hyhpoventilation in the presence of suspected drugdose. 4. Persistent hypoxemia (regardless of FIO2).
In Adults What is the 9 initiations of Mechanical ventilation? 1. Rate. 2. Vt. 3. FiO2. 4. PEEP. 5. Mode. 6. Peak Flow. 7. Ideal body wt. 8. Best types of vents. 9. complications associated w/PPV.
What is the normal RR&VT to initiate Mechanical Ventilation (Adult)? Rate: 12-8/min and Vt: 8-12 mL/Kg.
What is the normal FIO2 to initiate Mechanical Ventilation(Adult)? FIO2: 1. Same as previous if available but don’t put on room air 21% 2. 30-60% if previous FIO2 is not known / on room air. 3. 100% if emergency.
What is the normal PEEP to initiate Mechanical Ventilation(Adult)? PEEP: Same as previous (CPAP values/ the expiratory side of BIPAP) 2. If no previous PEEP then any PEEP under 10 cmH20 is ok.
What is the normal MODE to initiate Mechanical Ventilation(Adult)? Mode: Any mode is ok. But pick in an order. Eg. SIMV/IMV-Assist control-control mode. All modes will ventilate.
What is the normal PEAK FLOW to initiate Mechanical Ventilation(Adult)? Peak Flow: must calculate appropriate flow.
What is the normal IDEAL BODY WEIGHT to initiate Mechanical Ventilation(Adult)? Use the given pt. weight in Kgs. unless paitent is obesse. To determine if obese 1.Look Height 2.Figure 106 lbs. for a 5 foot person 3. Add 6 lbs for every inch abouve 5 feet 4.Convert to kg (divide by 2.2) 5.If pt. < 5 ft. subtract 6 lbs/inch under 5 ft
In initiating Mechanical Ventilation When do we use Volume Cycled Ventilator? If there is any problem with the lung (ARDS,Pneumonia , COPD etc)
In initiating Mechanical Ventilation When do we use Pressure Cycled Ventilator? if there is any problem other that with the lung then use Pressure Cycled Ventilator(Neurological cases, drug overdose, myasthenia gravis, etc.)
What are the complications associated with positive pressure ventilation(PPV) to initiate a Mechanical Ventilation? Decreased Venous Return. 2. Decreased urine output – most likely thing to happen 3. Loss of dignity (due to inability to tale) 4. Development of ventilator dependancy.
What are the 7 methods to maintain a Mechanical Ventilation? 1.Monitoring Vent. Pts.2.Central Objectives w/ pts. On mech. Ventilation 3.Monitoring Readiness to wean/Stop Mech. Ventilation 4.Routine Measurements Monitors Ventilation 5. Modifying Ventilatory MODE. 6.Modifying Vent. PaCO2,PaO2&I:E Ratio 7.Vent. Alarms
How do you monitor a ventilator pt.? 1. Maintain vital function of ventilation 2.Oxygenation& ventilation requires the need to monitor its clinical & lab areas. 3. Decrease in Cardia Function & Changes in BP needs to be monitored. In Short, monitor everything.
What are the central objectives with patient on Mechanical ventilation? 1. GET THEM OFF the ventilator 2. Ensure adequate ventilation & oxygenation.
How do you monitor the readiness to wean or to stop Mechanical Ventilation? Pt. ready to wean if 1.All vitals stable 2. ABGs are good 3.Spontaneous VT > 5 mL/kg 4. VC> 10mL/kg 5. MIP> 20 cmH20 6.QS/QT <20% 7.Vd/VT < 60% 8. Underlying Problem is resolved Infection,Myasthenia gravis & Pneumonia is cleared
What are the 9 Routine Measurements that Monitor Ventilation? 1. Exhaled VT 2. Minute Ventilation (Ve) 3.VD/VT Ratio 4.Dynamic Compliance 5. Static Complaince 6.Determining cause of increased PIP. 7. Mean Airway Pressure (PAW) 8. Alveolar Ventilation 9. Dead space Ventilation
What is dynamic compliance? Dynamic Complaince = VT/(PIP-PEEP) 1. Associated w/ increased airway resistance (RAW) 2. Suction if sputum is present 3. Give Bronchodilator if Wheezing
What is static compliance? Static Complaince = VT/(Ppl-PEEP) 1. Acceptable Range 25-100mL/cm H2O. 2. Decrease in compliance indicates stiffening of Lungs. 3. Apply PEEP therapy 4. Monitor Vent. Pressure if over 50cm H2O,then change to different mode of ventilation.
What determines the cause of increased PIP? 1. PIP may increase because of increased airway resistance SHOWN BY INCREASE IN PEAK PRESSURE ONLY 2. PIP MAY increase due to decreasing lung compliance (lungs becoming stiff) SHOWN BY INCREASE IN PLATEAU PRESSURE & PEAK PRESSURE.
What are the 4 causes that increases Airway Resistance SHOWN BY INCREASE IN PEAK PRESSURE ONLY? 1. Secretions in the Airway 2. Kinked ET Tube 3. Excess water in the ventilator circuit 4. Bronchoconstriction(wheezing)
What are the 3 causes that decrease lung compliance (lungs becoming stiff) SHOWN BY INCREASE IN PLATEAU PRESSURE & PEAK PRESSURE? 1. ARDS 2. Pulmonary Fibrosis 3. Pulmonary Edema.
What is the determination procedure for PIP & Plateau Pressure? If both PIP & Plateau pressure has risen by roughly same amount over a period of time the cause is reduction in pulmonary compliance (ARDS). If only PIP has risen then cause is Increased Airway Resistance (need suctioning).
What is Mean Airway Pressure(PAW)? Total Avearge amt. of pressure applied to the airways & lungs from the beginning of one breath to the beginning of the next breath. Normal is 5-10cmH2O. Vent. Controls that affect Paw-RR,VT,PIP,PEEP,Peak Flow & Inspiratory hold time.
What is Alveolar Ventilation(VA)/ Alveolar Minute Ventilation? VA= (VT-VD) x f. 1. Increase VA by increasing VT. 2. VD can be estimated : 1 mL VD/ lb of ideal body weight.
What are the 4 types of dead space Ventilation? 1. Mechanical Deadspace 2. Anatomical Deadspace 3. Alveolar Deadspace 4. Physiological Deadspace
What is Mechanical Deadspace? 1. It is in the cirucit tubing between wye & pt. 2.Calculate about 10mL/inch of flex tubing.
What is Anatomical Deadspace? 1. All the anatomical space that cannot participate in gas exchange. It includes all areas except the alveoli. 3. Normal is 1 mL/lb ideal body weight.
What is Alveolar Deadspace? Alveolar deadspace if dysfunctional because there is no blood-flow to the area.
What is Physiological Deadspace? The anatomical & Alveolar deadspace combined is physiological deadspace.
What are the 7 Ventilator Modes? 1. SIMV / IMV MODE 2. ASSIT/CONTROL MODE 3. Control Mode 4. Pressure Control Ventilation (PCV) mode 5. Inverse Positive Pressure Ventilation Mode (IPPV) 6. Inspiratory Plateau Mode 7.High Frequency Ventilation (HFPPV)
What is SIMV/IMV MODE? 1. Good for weaning 2. Good for pts. Who breath on their own to a small degree 3. Less barotrauma 4. Avoid Hyperventilation 5.used on anxious pts. until sedation & then a control mode can be used. 6Consists of mandatory rate & allows spontaneos breathing
What is ASSIST/CONTROL MODE? 1. provides a set VT @ a set rate. Also, the set VT is delivered even when the pt. spontaneously intiates breaths above the set rate. 2. Good mode – works with most pts. 3.Alert pts. Find it uncomfortable may need sedative &Anxiety controlling medication.
What is Control MODE? 1.Used for unconsious pts. Does not allow pts. To determine Rate or VT. 2. Pts. Should be sedated or paralyzed 3. This mode is not common but will provide ventilation as good as any other mode.
What is Pressure Control Ventilation(PCV) mode? 1.Used when peak pressures are primary concerns-above 50 cmH2O by volume ventilation.2.No tidal volume setting-only inspiratory pressure and inspiratory time.3. Must set exhaled VT alarms. 4 good for High PIP&hypoxemia pt.5.Not a good initial vent. mode.
What is Inverse Positive Pressure Ventilation (IPPV) Inverse Ratio Ventilation (IRV) Mode? 1.Not a good initial mode. 2.SAME pt. as those eligible for pressure control ventilation (ARDS). 3. Useful for pt. requiring high peak pressures due to low lung compliance.
What is Inspiratory Plateau Mode? 1. Helps improve gas distribution (good). 2. Significantly increase mean airway pressure (bad).
What is High Frequency Ventilation (HFPPV) MODE? Includes High frequency.The main controls are-a.Drive pressure.B.% inspiratory time.C.rate.D.injector line.E. Peep.F. Fio2. *USE the drive pressure, rate and %IT to change ventilation.
HFPPV Is used on What patients? Used for pt. with ARDS/other problems w/markedly decresed compliance
What are the Ventilator Controls that affects PaCO2? 1. Mechanical deadspace. 2. Tidal volume and 3. Rate.
What should we do if PaCO2 is between 35-45mmHg(Normal)? Do not change anything if PaCo2 is b/w 35-45 mmHg.
What should we do if PaCO2 is HIGH? 1. First-remove deadspace if PCO2 is only off by 1 point. 2. Second-increase VT but stay in the correct range. 3. Third- Increase rate (most common, but only choose if first 2 are not options OR the PaCO2 is 4 mmHg/more from target.
What should we do if PaCO2 is LOW? 1. First-add deadspace if PCO2 is only off by 1 point. 2. Second-lower rate. 3. Third- lower VT but stay in range. 4.*The order of priorities relates to MAP-they are done so that MAP is kept low as possible.
What are the Problems that affect PaCO2? 1. Pt. is over-ventilating-reduce rate/sedate pt. 2. Pt. is under-ventilation-increase rate/help overcome resistance w/PS. 3. Return vol. is inadequate. 4. VD/VT too high (deadspace disease-pulmonary embolism)-diagnosis w/ VQ scan & treat.
If return volume is inadequate in PaCO2 how can it be correct this? 1.Ensure set VT.2.Look for leak around an ET cuff&circuits.Look for vol. leak thru a chest tube&drainage system.3.If using pressure-cycled vent.Ensure operating pressure High. If using baby vent. Ensure flow is appropriate. Make sure flow rate is high.
What should we do if PaO2 is Low? 1. Raise FIO2 by 5-10% until you reach 60%. 2. Then add/raise PEEP by 5cmH2O.3. If PEEP gets very high (above 20 cm H2O) watch hemodynamics & CO.4. If CO falls then lower PEEP to the last previous value & begin raising FIO2 if hypoxemia persists.
What should we do if PaO2 is High? 1.Lower FIO2 until below 60%-then begin lowering PEEP. 2.If FIO2 is 60%/below, then immediately focus on PEEP.3. Lower PEEP by decrements of 5 cmH2O. 3. Move FIO2 by 5-10% @ a time.
What is I:E ratio? 1.Changing I:E refers to changing the I. 2. It is controlled by adjusting the peak flow. 3. Increasing peak flow = decrease I time and Increase E time. The opposite is true. COPD needs a longer expiratory time. Normal I:E = 1:2, E is greater than I time.
What is adding of Pressure support (PS) mean? PS overcome resistance of circuit tubing during spontaneus breathing. PS is set above normal resistance offer subtle increase in vent pressure. Helps spontaneous breathing pt. accomplish larger vt. Helps to wean pt. keep vt above 5ml/kg.
What is Expiratory retard? 1 Allows slower expiration.2.reduces air-trapping.3.promotes complete exhalation. 4.decreases auto peep. 5 Good for pt. w/high lung compliance.6. decreases I:E ratio, need to adjust peak flow to compensate.7.increaseS MAP unless rate/peak flow is adjusted
What is an inflation hold? 1. Good for pt. w/low compliance. 2. Promotes better distribution of gases. Holds pressure @ the complete delivery of VT. 3. Drastic increase of MAP so don’t use on head injury/hypotensive pts.
What do you mean by Mechanical sighs? 1. Helpsful in preventing atelectasis. 2. Usually 1.5-2.0 times the VT 3. Aprropriate rate is 1-3 sighs every 5-10 minutes.
What do you mean by optimal PEEP by airway graphic? 1. A pressure/vol loop is seen to determine optimal PEEP setting.2.objectives is ensure there is increse in vol. w/rise in pressure. 3.flat spot on graph is undesirable-so increase peep till flat spot is gone,shows vol is delivered and pressure is applied
What do you mean by optimal Vt by airway graphic? 1. A small beak is seen on the graph. 2. If a large beak exist then it takes a lot of pressure to get in the last bit of VT. 2.May have to lower VT a little to protect the pt. from excessive pressure.
What is Auto PEEP? .
What do yo mean by Inflection point in an airway graph? It may refer to this as the point in any graph where the curve changes direction/alters ut path significantly.
What are the 2 vent. Alarms? 1.High pressure alarm and 2. Low pressure alarm.
Why does high pressure alarm? 1. Set @ 10-15 cmH2O above baseline peak pressure. 2. Could be excess secretions in the airway-suction.2. Herniated ET tube-replace. 4. pt. coughing. 5. Decrease in lung compliance. 6.Pneumothorax. 7. Pinched/excess H2O in the circuit. 8. Clogged HME.
Why does Low pressure/volume alarm? 1.Set about 10 cmH2O below baseline peak pressure.2.Could be under-inflated/deflated ET tube cuff-add air/replace ET tube.3.Leak in cuff-replace ET tube. 4.Disconnected/leak in circuit. Hole lung tissue in presence of chest tube drainage system.
What are the other types of vent. Alarms? 1. High/low O2 alarms set about 5% above and below FIO2. 2. Temp. alarm. 3. Low minute volume alarm. 4. Power alarm-check electrical cord and power source. 5. Source gas alarm-check for sufficient pressure in bulk system.
What are the 5 qualifications to wean a patient? 1. Underlying problems must be resolved. 2. Spontaneous vent. Ability. 3. Calculated evidence that supports weaning. 4. normal vitals
To wean what are the underlying problems that must be resolved? 1.This pertains to problems such as infections and pneumonia. 2. Does not mean the pt.must be cured from a disease such as COPD etc.
In order to wean what is the correct acid/base balance w/vent. Support? ABG’s must be in acceptable range.
In order to wean what are the spontaneous ventilatory ability to wean? 1. Vt – > 5 ml/kg 2. VC > 10 mL/kg. 3. MIP > -20 cm H2O 4. MEP > 40 cmH2O 5. RSBI -< 106 (RR/VT) – rapid shallow breathing index. 6. RR- 8-20 bpm 7. Ve – < 10 L/m.
what is the calculated clinical evidence that supports weaning? 1.VD/VT – <60% 2. QS/QT – <20% 3. A-aDO2 – <300 mmHg If pt. don’t meet these then they wont be permitted to wean.
In order to wean what should be the normal vital signs? 1. Normal Pulse – 80-100. 2. Normal BP-120/80. 3. Normal temperature-37 degree C.
What are the 6 weaning methods and procedures? 1. cold cessation of mechanical ventilation. 2. slow, decremental changes in frequency FIO2, PEEP and PS. 3. PS ventilation. 4. Weaning failure 5. General weaning consideration. 6.post-cessation analysis.
In weaning method what do you mean by slow decremental changes in RR, FIO2,PEEP and PS? 1. Swithc to SIMV/IMV mode if not alreadly on. 2. Decrese rate by 2, monitor vital and spontaneous ventilation. 3. Decre PEEP by 3-5 vmH20 @ a time. 4. No need to go below a rate of 4/min. – may stop mech. Ventilation @ that point.
How does PS ventilations do during a weaning method? 1. Set at a pressure greater than airway and circuit resistance. 2. Initially assure adequate VT during spontaneous breathing. 3. Decrease by 2-5 at a time, monitor VT.
How is a weaning failure defined? 1.If HR 20 bpm above pre-weaning rate.2vBP rises 20 above baseline. 3. VT< 5 ml/kg. VC< 10 ml/kg. 4. Pt. shows signs of confusion/ Any changes mentally/becomes unresponsive.7If PaCO2 becomes 10 torr.8.If RR goes 10&Total rate goes 30 /min.above baseline.
What are some of the general consideration of weaning method? 1. Stop all sedations that suppress the resp. drive. 2. No need to reduce FIO2 below 40% and PEEP below 5 vm H20. 3. Wean during daytime hrs. Should not be done if short-staffed. Follow O2 weaning rules.
In a weaning procedure what should be done to a post-cessation analysis? 1. ABG should be drawn every 20-30 min. following a removal of vent. Support. 2.Vitals, VC, VT must be measured every 20 min.3. Pt. may not/may remain intubated.Do not confuse extubation/intubation w/ the cessation/beginning of a vent support respectively
What are the 2 general consideration of a Full ventilatory support? 1. Pharmacology and 2. Postitioning method for patient’s
In full ventilatory support what are the 2 pharmacology methods for a pt. ? 1. Facilitates intubation and 2.Anxiety and pain reliever
During a Full ventilatory support to faciliate Intubation what are the 3 medications given to a pt. ? 1. Anectine, 2. Pavulon and 3. Curare.
How does Anectine (succinylchloride) help? 1. it is a short and quick acting medication. 2. The drug is working when a muscle twitching is observed about the face, neck and the upper chest.
How doesPavulon (Pancuronium Bromide) help? 1. Total muscle relaxant and 2. takes less than 3 minutes to work.
How does Curare (d-Tubocurarine) help? 1. Paralyses muscles and 2.reversed by atropine.
During a Full ventilatory support to relieve pain and anxiety what are the 3 medications given to a pt. ? 1. Morphine 2. Valium and 3. Versed.
How does Morphine sulfate help? 1. Relieves pain and anxiety. 2. It is a common medication. 3. Can decrease resp. drive therfore watch the pt. carefully. Avoid using this medication on a COPD pt. or monitor very carefully.
How does Valium help? 1. It relieves anxiety. 2. Anticonvulsant.
How does Versed help? 1. It relieves anxiety. 2. More common than valium but about the same action i.e Anticonvulsant.
In a Full ventilatory support what are the positioning method for a pt. ? 1. Semi-fowler’s position – best for gas distribustion during mech. Ventilation.