Question Answer
noninvasive positive pressure ventilation provides assisted ventilation without an artificial airway
NPPV may be used to assist patients with obstructive sleep apnea and acute ventilatory failure
NPPV provides ventilation via the patient’s nose or mouth without an artificial airway
NPPV is Noninvasive positive pressure ventilation
NPPV is ventilation without an artificial airway
NPPV may be used as CPAP or bilevel PAP
CPAP is Continuous positive airway pressure
CPAP uses positive airway pressure during spontaneous breaths
CPAP does not use mechanical breaths
CPAP is active when IPAP = EPAP
Bilevel PAP is Bilevel positive airway pressure also known as BiPAP
BiPAP provides IPAP and EPAP
During BiPaAP CPAP is active when IPAP = EPAP
IPAP is Inspiratory positive airway pressure
IPAP controls peak inspiratory pressure during inspiration
EPAP is Expiratory positive airway pressure
EPAP controls end-expiratory pressure
EPAP is used as CPAP when IPAP = EPAP
EPAP is used as PEEP when IPAP > EPAP
PEEP is Positive end-expiratory pressure
PEEP is PAP at end -expiratory phase
PEEP is used with mechanical breaths
IPAP is the level of airway pressure during inspiratory phase only
EPAP is the level of airway pressure during expiratory phase only
The degree of ventilation is directly related to the IPAP level
HIGHer IPAP level would result in Larger tidal volume and minute ventilation
The level of IPAP and EPAP can be titrated according to a patients oxygenation and ventilation needs
the two benefits of NPPV are an improvement of PO2 and PCO2
CPAP does not include any mechanical breaths
CPAP is the treatment of choice for obstructive sleep apnea without significant CO2 retention
OSA is caused by severe airflow obstruction during sleep
CPAP provides positive airway pressure during the entire spontaneous breath
During CPAP the work of breathing is entirely assumed by the patient
CPAP should be used with care and close monitoring of the patient as it is not effective in apnea due to neuromuscular causes
Sleep apnea is defined as a temporary pause in breathing that lasts at least 10 seconds during sleep
Sleep apnea is caused by Air Flow obstruction (OSA) or a loss of neurologic breathing effort (central sleep apnea), or a combination of these two conditions (mixed sleep apnea)
Indications for CPAP Obstuctive sleep apnea
Contraindications for CPAP Apnea due to neuromuscular causes, progressive hypoventilation, fatigue of respiratory muscles, facial trauma, claustrophobia
Apnea index is average number of apneas in each hour of sleep during a test
hypopnea is reduction in airflow for 10 or more seconds that is at least 50% below an estimated baseline amplitude.
hypopnea is usually associated with an oxygen desaturation or a pulse alteration
apnea-hypopnea index is average number of apnea and hypopnea in each hour of sleep during a test
desaturation index is average number of oxygen desaturations of 4% or more from baseline in each hour of sleep during a test
treatments for OSA include oral applications such as prosthetic mandibular advancement, surgical interventions such as tonsillectomy and uvulopalatopharyngoplasty for upper obstructions, and weight reduction gastric surgery for morbidly obese patients.
Risk factors for OSA include History of snoring and witnessed apneas, obesity, increased neck circumference, hypertension, and family history of OSA
OSA major clinical signs and symptoms are snoring, daytime sleepiness, restless sleep, morning fatigue, and headaches.
If untreated OSA can lead to hypertension, left and right ventricular hypertrophy, sudden cardiovascular death, and increased risk for brain infarction
BiPAP has how many pressure levels 2
CPAP has how many pressure levels one
PEEP is defined as an airway pressure that is above 0 cm H2O at end-expiration
Two indications for bilevel PAP are accute respiratory failure and acute hypercapnic exacerbations of COPD
BiPAP is different from CPAP in that BiPAP has two pressure levels, whereas CPAP has only one
In BiPAP has an IPAP setting that provides mechanical breaths
BiPAP has an EPAP setting that functions as positive end expiratory pressure
The most common criteria for the determination of acute respiratory failure blood gas results that typically show partially compensated respiratory acidosis with moderate hypoxemia
Patients that are not candidates for NPPV are unable to use or tolerate nasal or facial mask
Indications for NPPV reduction of respiratory workload in obesity, acute respiratory failure, acute hypercapnic exacerbations of COPD
Contraindications for NPPV Apnea, unable to handle secretions, facial trauma, claustrophobia
Interfaces for NPPV Nasal mask, facial mask, nasal pillows
Nasal mask is a mask that covers only the nose
A minor leak in a nasal mask is considered acceptable.
When a leak in a nasal mask is significant a facial mask should be considered
A Facial mask is a mask that covers the nose and mouth
Potential problems when using a facial mask include Regurgitation and aspiration
Advantages of using a Nasal mask Comfort, patient compliance
Disadvantages of using a nasal mask gas leaks, nasal dryness or drainage
advantage of using the facial mask good seal
disadvantages of using a facial mask claustrophobia, patient noncompliance, regurgitation and aspiration, asphyxiation in power or gas outage, alarm and monitor may be necessary
IPAP is an airway pressure above 0 cm H2O during inspiration
EPAP is an airway pressure that is above 0 cmH2O at end expiration
The initial CPAP setting is started at 4 cmH2O and titrated to the desired endpoint
What is RAMP the starting pressure is set low and gradually increases over time (up to 45 minutes) until the desired pressure is reached.
RAMP is ideal for patients who may have trouble tolerating a sudden onset of high pressure
What is C-FLEX a method of delivering CPAP for the treatment of OSA
The initial BiPAP pressures are started at 8 cm H2O (inspiratory, and 4 cm H2O expiratory pressure and titrated to the desired endpoint.
What is Bi-Flex A method of delivering bilevel PAP in which the airflow during inhalation and exhalation is “softened” this makes breathing more natural and comfortable for the patient
titration endpoints of IPAP and EPAP during bilevel PAP do not include PvO2
NPPV can not provide positive end expiratory pressure (PEEP)
Question Answer
What setting is more difficult for a pt to initiate a breath? Pressure
When will your high-pressure alarm go off and what is the normal setting for it? alarm will sound if delivered Vt is greater than what you have set, normal is 200ml above set vt.
If you have a pt with chest trauma what would you want his set flow to be above and what would you do to minimize barotrauma? flow above 60lpm, need to lower volumes and higher RR to minimize RR.
What setting is easier for the pt to initiate a breath? Flow
What flow pattern is used in pressure mode and what type of pt likes it? Descending and COPDers
If you have a pt whose set Vt is 600ml but is getting 850 ml what would you adjust and why? You would decrease pressure bc normal Vt is 200 ml above set Vt.
What are the normal ranges for flow and pressure? Flow 1-5 Lpm pressure -1 to -5 cmH2O
What would be settings for a normal post op patient? Mode SIMV Volume vt 10-12 ml/kg, RR 10-12bpm, iTime 1 sec, flow 40-60lpm, PEEP 5 cwp, FiiO2 start 100% and wean to keep >90%
If you had a patient come in with a closed head injury what mode would you pick and what initial settings would you choose to use? And what do you want to keep monitoring and why? Volume ventilation full, vt 8-12ml/kg, RR 15-20bpm, Itime 1 sec, flow 40-60lpm, peep 0cwp, FiO2 100%, monitor ICP and don’t do peep if its high also be careful when auctioning and coughing
What would be the limiting mechanism in a SIMV pressure mode? Pressure
You have a pt admitted with COPD exacerbation. Which mode is most beneficial to them, and what range would you set the trigger? Pressure control, -1 to -5cmH2O
A COPD pt is admitted, and are on Pressure Control, what flow patterns will you see? This will also require a ___ ___ to maintain the same Itime. Descending Flow Patterns, requires a higher flow
What is the normal range for pressure sensitivity? The normal range is -1 to -5 cm H2O
What type of ventilation would we use for normal lungs when other systems are shutting down? What settings are used? Volume ventilation, 10-12 ml/kg, 10 12 bpm, Itime of 1 sec, 40-60 lpm, 5 cm H2O, and initally 100% FiO2.
For a CHF exacerbation when would we not want to use volume ventilation? What is the Itime range, and why is it that? We would not want to use volume ventilation if PIP is high, also we would want to consider using NIV first unless it is contraindicated. The Itime range is 1-1.5 sec because of the edema.
If there is a leak in the patient circuit, which alarm would be going off and what are the normal settings for this alarm? Low Pressure / PEEP Alarm 10 below PC or PIP or 3-5 below PEEP
What is sensitivity? how the patient initiates a breath
What is the normal high VE alarm? 10L above resting VE
What mode of ventilation would you use for an ARDS pateint? What settings are NOT SET in this mode? Pressure Ventilation–volume and flow vary not set
What mode would you use for a closed head injury patient if there are no lung injuries? What are some things you want to minimize when working with these patients and why? Volume Ventilation–minimize noise, times in room, suctioning–helps keep ICP low
What type of flow pattern would you see when using Volume Control? Square
What Itime would you use for a patient in a CHF exacerbation? What is the purpose of using this Itime? You would want to use an Itime of 1-1.5 seconds. The reason we want a longer Itime is to use that pressure as a way to decrease the edema associated with a CHF exacerbation.
You have a patient who was found unconscious in Wal-mart, but no one saw or knows anything about them. What initial settings would you use for this patient? Mode: VC Vt: 8-10 ml/Kg RR: 8-12 bpm Itime: 1 sec PEEP: 5cmH2O FiO2: 100% and wean
If flow is being added to a circuit such as an inline (SVN) aerosol Tx what type of Trigger/ sensitivity would you want to set for your Pt? Pressure Trigger/ sensitivity
35yr M 6’1″ 172lbs in route to ER found outside a bar unconcious with lacerations to face & chest was intubated in the field & difficult to bag. Vitals- RR-12 HR-114 B/P-132/91 SpO2-72% on 100%BVM What would be the ideal mode & settings for this pt? Mode- VC Itime-1sec FiO2-100% Tv-840ml(8-12ml/kg) Etime- 4sec RR-12 I:E- 1:4 PEEP- 5cmH2O Flow-50Lpm
Your pt’s vent is alarming a High Pressure High Alert Alarm. What are specific causes of this alarm? What is the vent currently doing with each breath while this alarm sounds to protect the pt? Causes- Coughing, kinking in circuit or ET tube, Secretions, decreased compliance, increased Raw, mucous plugging- causes an increase in pressure readings for vent. The vent protects pt by dumping each breath once the pressure limit is reached.
What would the normal flow be for a post op hip surgery patient? 40-60Lpm
A 5’2″ child has come to the ED for an asthma exacerbation. She is 50kg. What would her target Vt be and what would you set her Itime at? Target Vt 261-522 Itime 0.8 sec.
A pt has come to the ER after an MVA. He potentially has increase ICP and needs to be placed on the vent. What mode would you put him in? Would he need to be on PEEP? If so what PEEP? And what RR would he need to be set at? Volume ventilation. Maybe PEEP. 0-5cwp but closely monitor because of ICP. And a set RR of 15-20bpm
What are the two most common flow patterns you will see? and which mode would you see them in? Square-Volume modes, Descending-Pressure modes.
A male pt, 6’3″ 215lbs, comes into the ED with pneumonia that is progressively getting worse. The physician asks you to set up the vent for this patient, What would your initial settings be? Mode: PC VT: 575 mL/kg RR: 20 I time: 1 second Flow: 65lpm PEEP: 8 cmH2O FiO2: 100%
What is the purpose of permissive hypercapnia? To decrease PIP and the chance of causeing barotrauma.
What is the term for when a COPDer needs to be mechanically ventilated while they also have a respiratory infection? acute-on-chronic respiratory failure
What mode should you set a patient that has chest damage from an MVA? What would his tidal volume be at if he was 5’7″? You would set him on pressure ventilation mode. His Vt should be around 675 ml.
What are the three levels of alarms during mechanical ventilation? Which level is the most concerning? What are a few examples of that level? Level 1: Immediately life-threatening and includes failure of electrical power, exhalation valve, or timing. There can be excessive or no gas delivery to the patient. Remaining 2 levels are potentially life-threatening and non-life threatening
What alarm cannot be silenced if gas is critical to vent operation? Low-source gas alarm
What is permissive hypercapnia? Allowing PaCO2 to rise slightly so we can give small Vt and higher RR to decrease the chance of barotrauma.
What are some considerations for patients with closed head injuries? Minimize noise, time in the room, coughing and suctioning.
What alarm can not be silenced? High Pressure
A 5’2″ male child comes in ER with an acute asthma attack and needs to be ventilated what form of ventilation would you place him on? Pressure ventilation
5’2″ male child asthma exacerbation on Pressure ventilation would have what setting? vt:268-536 rr:8-10 Itime: <1sec Flow: 80-100 Peep: 0-5
If you are in VC, and your high-pressure alarm is going off, what is possibly the problem? The patient’s lungs have decreased in compliance causing an increase in PIP.
With a closed head injury, why would we use volume ventilation? We treat them like normal lungs since their injury is not to their lungs. They do have the potential to have other injuries involving the lungs, then we would reassess the situation.
44 yo male in an MVA with head trauma (no lung injuries). He is 5’10” and weighs 190 lbs. Vitals: HR 120, RR 12-15 (bagged), BP 90/50, unconscious and unresponsive to stimuli. Set up the initial vent settings. VC, VT 610 ml, RR 16, Itime 1 sec, flow 36.6, peep 0, trigger 2 lpm. we would watch his ICP to keep <12.
Why do we allow for bigger tidal volumes for neuromusclular diseases? It allows for the patient to meet their “air hunger” needs.
What is a reason for permissive hypercapnia and which type of patient do we use this for? Permissive ventilation allows for a decrease in PIP which decreases the chance for barotrauma. Vt is smaller but we increase RR to keep the same Ve. ARDS pts can benefit.
If we add flow to the mechanical vent, what setting might we have to change? We might have to change our trigger from flow to pressure.
What are two methods of setting a trigger? Flow and Pressure.
permissive hypercapnia is used to treat what disease process and what does it do ARDS, high RR low vt to prevent high PIP/barotrauma
with a neuromuscular pt. give a mode of ventilation over the disease progression minimal support, SIMV volume, VC, PC
Which type of trigger should be used when flow is being added to the circuit, like with a nebulizer? pressure
The two types of triggers are what? What are their units of measure? Are they positive or negative values? Flow and Pressure. Flow is in LPM and is positive. Pressure is in cmH2o and is negative.
If a patient is female, 5’5 with normal lungs on VC, what should the set Vt be? What should the high and low Vt alarms be set at? 590mL-709mL (10-12mL/kg) High Vt 200mL above set Vt Low Vt 200mL less than set Vt *if spontaneous breaths (SIMV-vol) then 100mL less than set Vt
If a patient is having trouble triggering a breath when we add additional flow to a circuit we switch to pressure triggering. Why? If, for example, we have a flow trigger set to 2 lpm and add an additional 8 lpm via a nebulizer the patient trigger is now 10 lpm. This is now more difficult for the patient than 2 cwp.
Which flow patterns are the most common on a ventilator? Square- often seen in volume modes Descending- often seen in pressure modes
Set Your Alarms: VC- Vt- 670 mL, RR 12 bpm, VE 8.04 L, PEEP 5, FiO2 45%. High Vt: 870 mL, Low Vt: 470 mL, High VE: 18 L, Low VE: 2 L, High RR: 22 bpm, Low RR: 6
What alarm can not be silenced due to safety concerns? High-Pressure Alarm
What type of ventilation do you want to use for a pt with an acute lung injury? Pressure Ventilation
A pt is 71 inches tall and with ARDS. What type of ventilation and what VT are you trying to achieve? Pressure ventilation trying to get VT of 780ml but watch for high pressures.
What type of patient might we need to put into permissive hypercapnia? ARDS pts may require permissive hypercapnia if normal settings are not working.
A pt is being brought in VIA EMS, they were found lying in an alley. The pt is female and 5’4 and unresponsive, no other info is given at his time. The physician wants you to place the pt on a vent, what setting would you choose? You would want to start patient in VC to rest them. Vt range: 448-672ml
Why is using pressure to ventilate a pt with a closed head injury not recommended? Using pressure to ventilate will increase ICP and may cause further damage to the pt.
What happens to a mechanically delivered breath if the high-pressure alarm is reached? The alarm will sound and the breath will be terminated.
Which alarm settings can be triggered by a leak? Low pressure, Low Vt, and Low VE.
If your patient has Vt of 4-8 ml/kg and RR of 15-25 bpm, what disease process does this person probably have? Why would you set the Vt and RR in this way? ARDS. A smaller Vt and higher RR will decrease the chance of barotrauma and minimize PIP.