Question Answer
Indications When a procedure should be done
Contraindications Reasons a procedure should not be done
Hazards Something that could happen during a procedure
Indications for artificial airways SAVO -suctioning -aspiration -ventilation -obstruction
Indications of oral airways Maintain patient airway on Unconscious patient, helps keep tongue off back of throat
Indications for Nasopharyngeal airways Facilitate suctioning -maintain airway in conscious patients
Contraindications for oral airways Do not use with conscious patients
Hazards of oral Airways Gagging, fighting away, tongue obstructing airway, epiglottis pushed into laryngeal area, Trauma due to improper insertion.
Hazards of Nasal Airways Aspiration if airway is too small, nasal irritation, bleeding
Ventilation volume of air inspired per minute. 4-5L/min
Perfusion Amt of Blood flow back to lungs. 5L/min
Deadspace Vent w/out perfusion, High VQ, cause by Pulmonary Embolus
Shunt Perfusion w/out vent, Low VQ, cause by Atelectasis, Pneumonia, ARDS
PaO2/FIO2 (PF) ratio < 300 acute lung Injury >300 normal < 200 ARDS- severe de-oxygenation
PaO2/PA02 range norm 0.75 normal range 0.75-0.95 <30 poor o2 transfer and increased shunting. <15 is critical
Responsive Hypoxemia low PO2 goes up with supplemental O2 -due to VQ mismatch
Refractory Hypoxemia PO2 doesn’t go up with supplemental O2. -caused by shunting
Anatomic Deadspace Gas volume in the conducting airways
Alveolar Deadspace Gas which does not reach functioning gas exchange units
Mechanical Deadspace Re-breathed gas from mechanical attachments
Vd/Vt (measures deadspace) PaCO2-PECO2 over PaCO2 -30% of each tidal volume breath is deadspace ventilation
normal Vd/Vt 30% normal range 20-40% -Vd/Vt increases in sick people -pulmonary embolus causes high Vd/Vt
Lung Compliance Stretchablity of lung -Normal Cl 200ml/cm H2O or 0.2 L/cm H2O
Thoracic Compliance Stretchability of the Chest Wall – Normal 200ml/cm H2O or 0.2 L/cm H2O
Static Compliance Plat- compliance with no airflow. -altered by changes in lung compliance & thoracic compliance
Dynamic Compliance Peak- compliance during airflow -altered by changes in lung and thoracic compliance. Can Also be altered by changes in Airway Resistance
normal compliance values 0.05 to 0.17 or 50-170ml/cm H2O
Factors that alter compliance (lung, thoracic, static, dynamic) congestion (congestive heart failure, pulmonary edema) atelectasis, fibrosis, pneumonia, emphysema
Causes of resistance Bronchospasm, secretions, obstructions, Small ET and Trach Tubes, High Insp. flow rates, Foreign bodies, Biting on ET tube
Airway Resistance calc. Peak-Plat/Flow (L/Sec)
Dynamic Calc Vt/Peak-Peep
Static Calc. Vt/Plat-Peep
30 is 60, 60 is 90, 40 is 75 PO2 30=Sat 60, PO2 60= 90 Sat, PO2 40=75 sat (venous blood)
reason suction cath is hard to advance pt biting down, kinked ET tube, Cath. too big
Normal PH 7.35-7.45
Normal PaCO2 35-45 mm Hg
Normal PaO2 80-100 mm Hg
normal HCO3 22-26
Alveolar minute ventilation (Va) first calc Vd -Vd= Vt(Vd/Vt) fill for VA= (Vt-Vd)f
How to increase minute vent Increase Tidal Volume or RR
Factors that alter thoracic compliance- CW changes outside the lung kyphoscoliosis, pectus excavatum, ascites, obesity, chest strapping, diaphragmatic impairment
factors that affect airway resistance Smooth, laminar flow & wide/straight airway = decrease resistance Rough turbulent, Narrow/curved = Increase resistance
Signs of respiratory distress Cyanosis, >RR, Increase HR, Increase BP
adequate tidal volume 600ml-800ml adults, 70-300 pediatric, 20-70 infant (needs manometer)
how many times to bag pt during code 10-12
liter flow of ambu 10-15 adults 5-10 children
Nasal airway lies btwn the base of tongue & post. wall of pharynx
LMA for emergency- cuff rests against the upper esophageal sphincter
PMA Displaces glottis and opening sits above larynx
Reflexes pahryngeal- gag & swallow, laryngeal- laryngospasm, Tracheal- coughing, Carinal- coughing
ET tube size Adult Male 8-9 / 23-24, Adult female 7-8 / 22-23
Rae Tube Curved- reduces kinks and disconnects. for nasal surgery, ophthalmic, facial, T
Endobronchial Tube double lumen- for thoracic surgery, broncho-spirometry, thoracoscopies, selective lung ventilation, Lung Lavage
Combitube Double lumen
Mallinckrodt Hi-Lo 2nd lumen hooked to suction to remove secretions (decreased infection)
Macintosh blade curved, inserted into vallecula to indirectly lift epiglottis
Miller straight, placed under epiglottis to directly lift
Immediate complications ET tube tooth trauma, laceration of pharynx, esophageal intubation, right mainstem intubation, damage to vocal cords
Late complications ET tube Contamination/infection, cough mechanism reduced, damage to vocal cords, laryngeal or tracheal edema, mucosal damage, tube occluded w/ secretions, loss of ability to talk, loss of dignity, trachoesophageal fistula
Tracheostomy indications bypass upper airway obstruction, reduce anatomic deadspace up to 50%, preventa probs w/ oral and nasal ET tubes, allow pt to swallow
tracheostomy complications (immediate) pneumothorax, bleeding, thyroid injury, subcutaneous emphysema, pt discomfort
late tracheostomy complications hemorrhage, infection, airway obstruction, tracheoesopheal fistula, interference w/ swallowing, stomal stenosis, tracheitis, rupture of the innominate artery
cufflator keep <20 torr or 26 cm h20, >30 ischemia, >20 congestion, >5 edema
minimal occluding volume start w/ leak & end up w/out a leak
minimal leak fill w/o leak & pull until you hear a minimal leak
Suction catheter sizing (Size of airway x 3)/2 ex (8×3)/2 = 12
Coud’e angled for endobronchial procedures
Closed Suction no sprayback (reduced contamination), soft tip reduces trauma
HME absorbs water vapor from exhaled gas use <96 hrs try to change every 24
Heated humidifier uses sterile water, helps prevent or loosen thick retained secretions
Normal VQ .8
Cuff inflated ventilation
Cuff deflated Speech
Question Answer
SIMV stands for? Synchronized Intermittent Mandatory Ventilation
This type of mechanical ventilation allows the patient to breath spontaneously while the ventilator provides a minimum minute ventilation SIMV
This mode of ventilation is used with COPD patients to normalize ABG’s mainly because it allows the patient to set their own rate and pattern SIMV
This mode of ventilation is used with patients experiencing tachypnea to avoid hyperventilation and also pulmonary embolis SIMV
This mode of ventilation is used for weaning patients from the ventilator SIMV
This mode of ventilation is used to reduce barotrauma ((the excessive pressure in the thorax)) SIMV
This mode of ventilation is used with PEEP (Positive End Expiratory Pressure) to reduce barotraumas SIMV
This mode of ventilation allows patient to set the respiratory rate while the ventilator will maintain a minimum rate. Any patient initiated breathing will result in the patient receiving either the pressure or volume set by the machine. Assist/Control Mode
This mode of ventilation is not good if they are hyperventilating Assist/Control mode
This mode of ventilation, the machine will self-cycle at a preset rate. It does not allow patient to initiate ventilation. Control Mode
With this mode of ventilation, Non-apneic and non-sedated patients will often “fight” the ventilator, requiring sedation and/or paralyzation. Control Mode
This mode of ventilation is indicated for head trauma/surgery patients (for induced hypocarbia), status asthmaticus, flail chest, etc.. Control Mode
With this mode of mechanical ventilation, only the patient can initiate ventilation. It is used with IPPB type treatments and is not recommended for continuous ventilation. Assist mode
Name the four modes of mechanical ventilation as discussed in class> 1) Assist Mode, 2) Control Mode, 3) Assist/Control Mode, 4) SIMV (Synchronized Intermittent Mechanical Ventilation) Mode
What are the 4 goals of therapy for the mechanically ventilated patient? 1)provide pulmonary systm suppt needed to mntain adequate alveolar ventilation 2)reduce wk of breathing until the cause of resp failure is removed 3)restore normal a/b balance 2 the arterial & systemic areas 4)increase O2 xfer & O2nation 2 body organs/tis
What is the standard criteria for the institution of the Mechanical Ventilatory Support? 1) Apnea or absence of breathing when reversible disease is present (absolute indication) 2) Acute Respiratory Failure 3) Impending respiratory failure 4) Severe hypoxemia attributed to increased work of breathing or an ineffective breathing pattern.
When Assessing Oxygenation needs, What are the Normal and Critical Value ranges for PaO2? Normal Range: 80 – 100 mmHg Critical Value: <70 mmHg (On O2)
When assessing Oxygenation needs, what are the Normal and Critical Value Ranges of P(A-a)O2 (also known as the A – a gradient)? 1) Normal Range: 2 – 30 mmHg 2) Critical Value: > 450 mmHg (on O2 Usually on 100%) (When you have an A-a gradient that high, the treatment will have to be a Positive Pressure O2 therapy, traditional O2 therapy will not help)
With the P(A-a)O2 or the A – a gradient, do you want the gradient to be wide or narrow? ((want the gradient to be narrow)) ((is the O2 in the Alveolar Level reaching the Arterial Level))
How do you calculate the Alveolar Equation (PAO2)? PAO2 = (PB-47) FiO2 – PaC02 x 1.25
What is the airway resistance equation? RAW = Ppeak – Pplat/Vdot (peak Flow) measured in LPM
What are the normal values for airway resistance? Normal Raw =.6 to 2.4 cmH20/L/Sec (this is normal healthy range)
What are the normal airway resistance values for a intubated pt? For an intubated person = 6.0 or > as Each ET tube size decreases the RAW Increases
What are the normal airway resistance values for a asthma and emphysema pt? 13.0 to 18.0
What is the formula for dynamic lung compliance CDYN = VT/PPEAK-PEEP
What is the formula for static lung compliance? CSTATIC = VT/PPLAT-PEEP
What are the three types of Mechanical Ventilation? 1) Negative Pressure 2) Positive Pressure 3) High Frequency
Attempts to mimic the actual function of the respiratory muscles to allow breathing through normal physiological mechanisms. Negative Pressure Ventilation
An example of a negative pressure ventilator is? the “iron lung”
True or False: In negative Pressure Ventilation, the negative pressure is generated throughout the thoracic area and is transmitted across the chest wall into the intrapleural space and finally into the intra-alveolar space True
True or False: During Negative Pressure Ventilation, the intra-alveolar space becomes increasingly positive in relation to the pressure at the mouth False: The intra-alveolar space becomes increasingly negative in relation to the pressure at the mouth ((at the mouth it is ambient))
True or False: During Negative Pressure Ventilation, expiration occurs when the negative pressure around the chest wall is removed and the normal elastic recoil of the lungs allow air to flow out passively True
Currently, the use of negative pressure ventilation is primarily seen and used where? In the Home Care Setting
This occurs when a mechanical ventilator literally blows air into the patient’s lungs by way of an endotracheal tube or mask. Positive Pressure Ventilation
During ___________ at any point during ___________ the inflation pressure at the upper airway will equal the sum of the pressures required to overcome the elastic resistance of the lung and chest wall and the resistance of the airways. a) Positive Pressure Ventilation b) Inspiration
True or False: During Postive Pressure Ventilation, the pressure in the alveolus progressively builds and becomes more positive. True
List the advantages of Pressure Support Ventilation 1) Supports Spontaneous VT 2) Decreases WOB 3) Assists in Weaning 4) Helps reduce Atrophy 5) Improves PT comfort 6) Decreases need of sedation
List the 3 indications for Pressure Support Ventilation? 1) Increase WOB 2) Weaning 3) Respiratory Muscle Weakness
What does Static Lung COmpliance MEasure? The Compliance of the lung tissue itself
What does Dynamic LUng compliance measure? Lung tissue and the thorax
What are static and dynamic lung compliance measure in? Or how are they measured ml/cmH20
What is the amount of time for an inspiratory pause or hold? .5 to 1.5 seconds
In pressure control ventilation, is used when PIP reaches what cmH2o? > than 50 cm/H20
Pressure control ventilation is recommended for FIO2’s above this number? >60%
Pressure Control Ventilation is also used for PEEP at what levels of cmH20? 15 cmH20
Respiratory therapists would use SIMV vs assist/control to reduce what? barotrauma
What mode can be used with most patients in most cases. assist/control
Question Answer
What is responsive Hypoxemia? Significant response to increase FIO2. Due to V/Q mismatch. A 20% increase in FIO2 = 10mmHg increase in PaO2
What is refractory Hypoxemia? No increase in PaO2 with increase in FIO2. Due to combo of anatomic and capillary SHUNT
What is Deadspace? Ventilation w/o Perfusion = High V/Q. From Pulmonary Embolism
What is Pulmonary/Capillary Shunt? Perfusion w/o Ventilation = Low V/Q. From ARDS, pneumonia, atelectasis.
Normal V/Q? they should match = 1.0 but normal is 0.8
PaO2/FIO2 (PF) ratio lower is worse. <300 = acute lung injury, <200 = ARDS
Normal PaO2/FIO2 (PF) ratio 400
Calculate Minute Ventilation RR X Vt(Tidal V)
Calulate VD/VT (PACO – PECO)/PACO, Normal VD/VT = .30, pt w/Puml. Embolis have higher ratios
Calculate Effective Minute Ventilation VA = (1-VD/VT) x RR x Vt
Calculate Static Compliance Remember Stat = Plat, Vt/(Plat – PEEP if any)
Normal Static values 0.05-0.17 L/cmH2O or 50-170ml/cmH2O
Static measures what? Lung Compliance w/o airflow
Calculate Dynamic Compliance Vt/(Peak – PEEP if any)
Dynamic measures what? Airway resistance during airflow
Static Compliance is altered by changes in Lung and Thorcic compliance
Dynamic Compliance is altered by Lung, Thoracic AND AIRWAY Resistance
Calculate Airway Resistance Peak-Plat pressure/Flow
Normal Airway Resistance Value 1-2 cmH2O/L/sec, Athsma and Emphysema is 13-18
Tissue Resistance caused by non elastic tissues in contact with Respiratory Tract, i.e. great blood vessels, certain muscles, and some upper ab contents
Name the 3 Deadspaces Anatomical, Alveolar, Mechanical
Anatomical Deadspace Conducting Airways
Mechanical Deadspace Re-breathed gas from Mechanical attachments
Alveolar Deadspace Gas not reaching functioning gas exchange units
What alters THORACIC Compliance Shit that affects the chest wall, Kyphoscoliosis, Pectus Excavatum, Ascites, Obesity, Chest Strapping, Diaphragmic impairment
Factor that alter LUNG, THORACIC, STATIC, and DYNAMIC Compliance Congestion(CHF, Pulmonary Edema), Atelectasis, Fibrosis, Emphysema, Pneumonia
Relationship between PACO2 and pH When starting at PACO2 of 40, for every 20 increase, the pH decreases .10, … for every PACO2 decrease of 10, pH increases by .10
Changes in BiCarb caused by PACO2 for every 10 increase in PACO2, HCO3 increases 1,…for every 10 decrease in PACO2, HCO3 decreases 1.5
30 is 60, 60 is 90, and 40 is 75 If PO2 = 30 sat is 60, 60 is 90, and 40 is 75(VENOUS)
If suction cath meets resistance… get tube with smaller diameter.


Question Answer
What is the formula to determine the Required FiO2? Required FiO2 = Desired PaO2 * Known FiO2/Known PaO2
This FiO2 percentage is initially used to help relieve tissue hypoxia and/or calculate shunt… Until an ABG is performed to get more precise data 50% to 100%
What are the three measurements used to manipulate the I:E ratio? 1) Peak Flow 2) Rate or (f) frequency 3) Tidal Volume
The Manipulation of the I:E ratio is a function of these three measurements? o Peak Flow o Rate or (f) frequency o Tidal Volume
What happens to the Inspiratory & Expiratory Time if you increase the peak flow? Inspiratory time will Decrease and the Expiratory time will increase
What happens to the Inspiratory & Expiratory Time if you increase the frequency or rate? You will increase the inspiratory time and decrease the expiratory time
What is considered an acceptable I:E ratio for a normal patient when initially setting up a ventilator? initial I:E ratio setting is 1:2
What is considered an acceptable I:E ratio for a COPD patient when initially setting up a ventilator? I:E ratio for a COPD patient is 1:3 or 1:4
How is Minute Ventilation (V.E) calculated and measured? It is calculated by multiplying the rate (F) times the Volume. It is measured in Liters per minute (LPM)
What is a typical normal minute ventilation range? Normal minute ventilation is about 5-6 L/min depending upon body size and oxygen consumption
What levels of minute ventilation would be considered abnormal or would cause concern? 10 LPM
How do you determine the predicted minute ventilation for a male with normal lungs and a normal metabolic rate? A female with normal lungs and a normal metabolic rate? For males you multiply the Body Surface Area (BSA) x 4. For Females it is the BSA x 3.5
How is the Body Surface Area (BSA) determined or how is it obtained? By the Dubois Monogram
If a 0patient is hyperthermic, do you change or compensate for the estimated minute ventilation? If yes how? The estimated minute ventilation must be increased by 9% for every degree Celsius above normal (37 degrees C. Conversely with Fahrenheit above 99 you would increase it 5% for every degree above 99.
What are the percentages for compensation if a patient is hypothermic? The estimated minute ventilation must be decreased by 9% for every degree Celsius below normal and 5% for every degree below Fahrenheit
Should the minute ventilation be adjusted in the presence of metabolic acidosis? If yes how? In the presence of metabolic acidosis the minute ventilation should be increased by 20%
In a metabolic acidotic patient, if you were seeing compensation, How would the CO2 be compensating in relation to HCO3? Would they be moving up or down? Would they be moving in the same or opposite directions? IF you were seeing compensation, the CO2 would be moving in the same direction as the HC03, moving downward
For seriously ill patients requiring MV, an initial setting of _________ to _________ times estimated minute ventilation is frequently used. an initial setting of 1.5 to 2.0 times’ estimated minute ventilation is frequently used.
How is the best way to provide adequate alveolar ventilation? By providing an adequate Tidal Volume
One of the biggest problems of Positive Pressure ventilation is? Barotrauma
How do you calculate an estimated tidal volume? 8 to 12 ml/kg of ideal body weight
What is one of the main reasons to maintain adequate tidal volume? to maintain homeostasis and/or proper acid base balance.
What is considered the “ideal” starting point for calculating tidal volume? The midpoint range or 10 ml/kg of ideal body weight
Name Two reason The tidal volume should not exceed 12 ml/kg of ideal body weight? Higher than 12 ml/kg tidal volumes will generate higher thoracic pressures and may result in 1) barotraumas and/or 2) reduced venous return
Tidal volumes below this amount should not be used? 4 ml/kg of IBW
If a low tidal volume of 4 ml/kg of IBW is prescribed for a patient, what other ventilator function usually accompanies this? The Sigh mode
If using the sigh mode, what sigh limit per minute is usually used in conjunction with low tidal volumes? 1 1/2 to 2 times the tidal volume. NBRC usually uses 7 times per minute
What is formula to caclulate Ideal Body Weight for a male? For a Female? For a male it is 106 pounds for the first five feet, and 6 pounds per inch over 5 feet. For a female it is 105 pounds for the first 5 feet. and 5 pounds for every inch over 5 feet.
What is the formula to calculate the respiratory frequency (f) or rate? Minute Ventilation/Tidal Volume V.E/Vt I.e. V.E of 6 LPM = 6000 ml. Tidal volume of 500 6000/500 = (f) of 12 BPM
What is the primary cardiovascular complication of mechanical ventilation? Reduction of cardiac output
Define Cardiac Output? It is a measurement of how much blood the heart forces or injects per beat
True or False: During spontaneous ventilation, the fall in intrathoracic pressure that draws air into the lungs also draws blood into the major thoracic vessels and heart True
True or false: With the Normal thoracic pump mechanism, the return of blood to the right heart and the stretching and enlargement of the right heart volume reduces right ventricular preload. False: Right ventricular preload is not reduced but enhanced.
True or False: With the normal thoracic pump mechanism, the stroke volume, or the amount of blood pumped per beat, also increases from the right heart. True
True or false: During exhalation, the return of blood to the left heart temporarily Decreases as blood from the right heart passes through the pulmonary circulation. (this is called left ventricular preload) False, the return of blood to the left side of the heart temporarily increases.
True or False: An increase in left ventricular preload increases left ventricular stroke volume (this is normal hemodynamic function and is a cyclical event – it maintains your cardiac output) True
True or false: During inspiration with positive pressure ventilation, the increased pressures are transmitted to the vessels and other structures in the thorax True