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SPC Mech Vent

SPC Mech Vent Units 6 & 7

What is Barotrauma? Excessive pressure damage
What is Volutrauma? Excessive volume damage
What is Atelectotrauma? Damage from constant opening & closing of alveoli
What is Sheertrauma? Damage from alveoli smacking/bumping into each other; over-distended alveoli bumping into healthy alveoli
What is Surfactant Alteration? Surfactant washing to the bottom of the alveoli instead of surrounding it
What is Biotrauma? Over vented pts prod chemicals that cause organs to fail (MODS - multi organ disorder)
What is VIDD? Vent. Induced Diaphragmatic Disfunction - muscle atrophy
What is Vent. Assoc. Lung Injury? Damage to area above alveoli caused by vent.
What is Vent. Induced Lung Injury? Damage to alveoli caused by vent (ex: alveolar sheer)
PPV can lead to: Increased WOB (Intrinsic & Extrinsic WOB)
What is Extrinsic WOB? A result of ET tube too small, vent. settings, vent. tubing
What is Intrinsic WOB? A result of trying to overcome the normal elastic & restrictive forces in the lung
Steps to reduce WOB in mech. vented pts: Use largest adequate ET tube possible; suction, Peep/PSV; correctly adjust sensitivity; adequate flow rates; decr. airway resistance w/ bronchodilators, diuretics, etc.
PPV can cause? Increase in deadspace due to over-expanded alveoli constricting blood flow
Decrease deadspace by: Increasing Vt, larger et tube, trachea
Results of hypoventilation: Acidosis, coma, hyperkalemia, increase in ICP, vasodilation
How long does renal compensation take to off-set HCO3? 18-36 hrs
Results of hyperventilation: Alkalosis, hypokalemia, tetany, decrease in cerebral perfusion, difficult weaning, vasoconstriction, lowers ICP, too long = Metabolic Acidosis due to HCO3 elevated.
Results of PPV on Pulmonary Blood Flow: Decreased CO, redistribute to lung periphery instead of central area, V/Q mismatch & physiologic deadspace, decrease shunting w/ PEEP
Results of PPV on Cardiovascular: Increase thoracic vessel pressures; Decrease venous return to thorax, pre-load, SV, CO, & systemic BP.
Results of PPV on Renal System: Decrease CO = decrease in urine formation & output; redistribution of blood flow w/in kidneys causes less urine, creatinine, & sodium excreted
Results of PPV on ICP: Increased central venous pressure = decr. venous return = incr. blood vol. in cranium = incr. ICP = decr. cerebral perfusion pressure = cerebral hypoxemia potential.
Clinical risks of PPV on ICP: Pts who already have incr. ICP, closed head injuries, cerebral tumors, post neurosurgery
Mean Airway Pressures (MAP): The average airway pressure throughout the vent cycle (I:E); affected by rate, I time, flow, pressure, or PEEP; MAP > 12 @ risk for barotrauma
Normal MAP: 0; less hemodynamic compromise if kept @ a minimum
Paw can be kept lower by: Changes in inspiratory gas flow & pattern, I:E ratio, PEEP, SIMV
Effect of ABG values on renal function: PaCO2 > 65mmHg = decr. renal function; PaO2 decr. due to vasoconstriction = decr. renal function; PaO2 < 40mmHg = dramatic decr. of renal function
What is Auto Peep? Inhaling too much & exhaling too little / air trapping.
Complications of Auto Peep: Barotrauma, tension pneumothorax, circulatory depression, incr. WOB, decr. CO & venous return
Results of Vent. Assoc. Lung Injury (VALI): Vent. Assoc. Pneumonias (VAPS); oxygen toxicity (ARDS); barotrauma (pneumothorax, pneumomediastinum, subcutaneous emphysema); over-distention of the lungs
Results of Vent. Induced Lung Injury (VILI): Altered lung fluid balance; incr. endothelial & epithelial permeability; severe tissue damage; collapse of the alveolar units.
Hazards of O2 therapy w/ Mech. Vent.: FiO2>60% more than 48hrs = N washout; FiO2 @ 100% can cause damage in 6 hrs; decr. compliance, surfactant prod., tracheal mucus flow; capillary injury; progressive formation of absorption atelectatis; possibly ARDS
What is alveoli instability? Opening & closing of alveoli (atelectotrauma) causing milking out of surfactant & alveolar instability
Causes of ARDS: A-airway pressures(peak & plat); R-refractory hypoxemia; D-diffuse infiltrates; S-some good lung
4 types of barotrauma assoc w/ MV: Subcutaneous Emphysema; Pneumodediastinum; Pneumothorax; Pneumopericardium
Body positioning w/ Unilateral Lung Disease: Independant lung ventilation (2 vents); pt's good lung is down.
Body positioning w/ ARDS: Prone (face down) - pt can develop swelling in face/head/eyes if not routinely turned.
Most important factor when evaluation pt for weaning: Was there a significant improvement or reversal of what caused the pt to be put on mechanical ventilation initially.
Weaning Parameters: Acid-base balance, anemia, cardiac arrhythmias, caloric depletion/nutritional status, fluid balance, hemodynamic stability, infection, physiological condition, renal function, state of consciousness, pain, sleep deprivation
VC (to wean): > 10 to 15 ml/kg
Ve (to wean): < 10 to 15 L/m
Vt (to wean): > 3-5 ml/lb or >300mL & <700mL
RR (to wean): < 25 breaths/min
MIP/NIP (to wean): -20 to -30cmH20
RSBI (to wean): < 100
Dynamic Compliance (to wean): > 25 mL/cmH20
Vd/Vt (to wean): < 60%
% Shunt Qs/Qt (to wean): < 20% to 30%
Physical signs of increased WOB: Use of accessory muscles; asynchronous breathing; sweating; anxiety; tachypnea; pt asynchronous w/ vent; substernal & intercostal reactions
3 Common Weaning Methods: T-Piece/Trach Collar Trials; SIMV; CPAP/PSV/Tube Compensation
Weaning w/ T-Piece/Trach Collar Trials: FiO2 5-10% higher than vent setting; monitor pts appearance, cardiac & ventilatory statuses, check ABG's, common in PACUs, always have pulse ox on pt for alarm purposes, for pts w/ only O in SAVO
Disadvantages to T-Piece/Trach Collar Trials: High level of staff attn; no backup ventilation; no alarms; incr. WOB
Weaning w/ SIMV: Assess pt; decr. rate by 2BPM; monitor vitals; check ABG's 20-30mins post vent chg; cont. to decr. SIMV rate as tolerated by pt; *Considered very old school
Advantages of SIMV weaning: Provides backup ventilation; provides a method of giving large, periodic breaths; useful in cases of ventilatory muscle weakness
Disadvantages of SIMV weaning: Incr WOB due to sudden incr in madatory rate; time & labor intensive; lots of ABGs; more side effects from ventilation (muscle atrophy)
Weaning w/ SIMV w/PS: Helps overcome system imposed WOB; pt controls frequency, depth, & time of spont. brths; improves vent. muscle endurance; PSV levels can be set to optimize a reasonable Vt for a pt
Weaning w/ PSV/CPAP: PSV levels set between 5-10cmH20; set spont. Vt's @ 300-600mL; set rate @ 15-20bpm; decr. psv levels by increments of 5 as tolerated
Weaning w/ Spontaneous Breathing Trials: Pt placed on spont. mode or CPAP w/ 0-5 PEEP; PS added @ a min. 5-7cmH20 to overcome WOB; hemodynamics & vitals monitored; ABG's; *Most common weaning method
Tube Compensation: Mimics post-extubation; weaning tool used prior to extubation; overcomes WOB due to artificial airway; assists pt w/ spont. breaths; Assist Mode = tube comp. ON; Control Mode = tube comp. OFF
Weaning w/ BiPAP: For pts w/ no need for invasive airway; used to avoid re-intubation
Evaluation for Discontinuance of Mech. Vent.: Need for airway protection; ability to mobilize secretions; ability to effectively cough; good gag reflex; ability to ventilate/oxygenate w/o airway assistance; hemodynamic/vital stability
Common causes for weaning failure: Attempted wean too soon; Incr secretions = incr WOB; physiological dependence on vent; generalized weakness & fatigue; malnutrition
Equipment for Extubation: Ambu bag, O2 source & mask/cannula, suction equip, supplies for re-intubation if necessary, Race-Epi
Procedure for Extubation: *Notify Nurse* Monitor pts appearance & vitals, Semi or High Fowler's position, Pre-Ox @ 100%, suction, loosen tape & deflate cuff, pt breathe in deep & cough - pull out tube @ cough, return FiO2 to pre-extubation rate, encourage pt to deep brthe & cough
Most COMMON Extubation Complication: Sore throat & hoarsenss
Most SIGNIFICANT Extubation Complication: Glottic Edema or Subglottic Edema
Glottic Edema: Usually involves the vocal chords & can be tx w/ cool mist, race epi, and/or heliox
Subglottic Edema: May cause complete obstruction requiring immediate re-intubation or emergency trach
Mild Stridor tx w/: Cool Mist (CAM)
Moderate Stridor tx w/: Race-Epi
Marked Stridor tx w/: Re-intubate
Long-Term Ventilation: Pts who are no longer acutely ill but who are presumed to have a permanent need for vent support
Created by: vgflgirl
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