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DrReedChp4

mech vent chp 4 test 3/1/18

QuestionAnswer
Barotrauma Hyperinflation of alveoli past the rupture point.
Points past the "rupture" point in barotrauma PEEP > 10; Mean >30; or PIP > 50; any pt hits PIP 50, change to PCV
Results of barotrauma Pneumothorax, tension pneumothorax, pneumomediastinum, tracheal shift
Causes barotrauma Volume control & a lot (too much) PEEP: should switch to pressure if this happens
Causes ICP? PEEP 8 to 12.
Complications barotrauma to renal function It alters renal function and water metabolism.
"clinical" guide for refractory hypoxemia When pts PaO2 is 60 mm Hg or lower at an FiO2 of 50% or greater.
Primary indication for PEEP Refractory hypoxemia caused by intrapulmonary shunting.
Causes of intrapulmonary shunting ↓ of FRC, atelectasis,or ↓ V/Q mismatch
Auto-PEEP Air trapping caused by severe airflow obstruction or insufficient expiratory time
Significant reason to use BiPAP To avoid intubation by using inspiratory and expiratory pressure difference.
BiPAP Bilevel Positive Airway Pressure: Applies independent positive airway pressures (PAP) to both inspiration and expiration.
Initial settings BiPAP IPAP 8 EPAP 4; Pressure is titrated based on pt need.
What is the difference between IPAP and EPAP for? The pressure support needed by the pt.
What are the correct increase increments for IPAP and EPAP? Always increase in increments of 2's as pt can tolerate.
What conditions should pt report immediately while using BiPAP? Headache, Chest pain, WOB or SOB
What is T-low? What is normal? The release time = 0.8 to 1 second is normal.
What happens with T-low at .05? Pt has less time to exhale Vt, most of Vt will stay inside.
What is status asthmaticus? You've given asthma treatment & doesn't help the pt. Usually requires "knock out" 24 hrs & vent support
Full ventilatory support (FVS) Provides all breathing support to pt
2 primary advantages of FVS? 1) Pts WOB ↓ & exceeds pts inspiratory flow demand. 2) Allows pt to control frequency.
Complications of FVS? Compensated Alveolar Hyperventilation, Respiratory alkalosis, pH ↑ and PaCO2 ↓
What is the only time we add additional tubing? When pt is brain-dead; to normalize pressure until get pts organs if organ donor.
Indications for partial vent support (PVS) Pt on AC for 24 hrs, then switched to SIMV. Give trial run, gradually, to see how pt does
Parameters for weaning? DO NOT WEAN until underlying condition is fixed.
Advantages to PVS? 1) Pt uses their respiratory muscles, so they won't atrophy. 2) Reduces V/Q mismatch, 3) ↓ MAP or mPAW
Why does partial vent support decrease MAP or mPAW? When pt is on AC. every breath is positive. When pt is on SIMV and spontaneously breaths, the breath is negative; this ↓ MAP
Why is Peak pressure not as important as MAP? Because the MAP is in the actual airway; If you ↑ MAP, then you ↓ RVR & ↓ CO
Complications of weaning SIMV mode Desire to wean too fast, must ↓ SIMV slowly and monitor closely
Why is it not a good idea to use MMV if pt has a high RR? Because on MMV mode, it will increase RR to reach the Ve you set. You can only use this if pt is breathing w/o spontaneous rate. Only use if pt has low Ve and low RR.
What is a good exception to MMV mode? On the Hamilton Veolar Vent, it operates as VS, augments spontaneous Vt, it increases PS, which in turn increases Ve
What is good about PC? I-time is your cycle
Can you use VS by itself? Yes, vent automatically adjusts the PS to reach the Vt you set.
Vented Expiratory valve opens to allow pt to cough
Time Triggered Mandatory allows spontaneous breathing
T-high how long to hold P-high
T-Low how long to hold P-low
If you find alarms set too high Document what you found vent set at, then document what you change it to. Protect yourself and pt
Normal release time 0.8 to 1 second; allows short time so can get breath in
BiPhasic PAP like APRV; except pt spends more time @ low level (expiration)
↑ MAP improved shunting
AutoPEEP refractory hypoxemia
CVP affects press coming to right side of heart
PAP affects pulmonary artery & lungs
Airway Pressure Amplitude Delta P/pressure, frequency = Hz. 3Hz=180, 5Hz=300; MAP adjusted according to set, iTime%, Bias flow=Exhalation pressure, FiO2
Max out Delta P Pressure then change frequency ↓
Bias flow 1st thing set, powers vent & allows pushing exhalation valve out= exhalation
MAP effected by iTime, PIP, PEEP, and RR
negative pressure ventilation alveolar pressure > atmospheric pressure
Mechanical breath ventilation positive pressure ventilation at airway opening
Mechanical Breath Variables Control, Trigger, and Cycle
Breath sequence Continuous mandatory, intermittent, continuous spontaneous
Type of control or target scheme Set point, Servo, Adaptive, and Optimal
Spontaneous Ventilation pt doing the work
PEEP positive end expiratory pressure: ↑ end-expiratory or baseline pressure to value greater than atmosphere; anything above zero
CPAP Continuous positive airway pressure; PEEP without a rate; all spontaneous breathing, no mechanical vent; to use pt MUST have adequate spontaneous breathing
CMV Controlled mandatory ventilation; Preset Vt, Time triggered; spontaneous vent from pt not possible.
AC Assist control; pt triggered, negative pressure deflection (below baseline), control = time trigger. It may be pt triggered or time triggered. Pt gets set Vt & Pressure. You can see what pt efforts are -- Danger: Hyperventilation!!
IMV intermittent mandatory ventilation; Not synchronized!; vent dlvrs mandatory breath & pt can breath in between
SIMV Synchronized intermittent mandatory ventilation; Synchronized! If pt attempts to take a breath, machine takes over instead of breath stacking. NBRC says 1/2 second before vent. Permits pt to breath spontaneously. "truly spontaneous"
MMV Mandatory minute vent: Provides Ve you set, mandatory frequency increases automatically; preventing hypoventilation & respiratory acidosis
PSV Pressure support vent: It lowers the work of the pt and augments spontaneous Vt b/c of ett & vent circuit
ASV Adaptive support vent: changes #of mandatory breaths & PS according to pt; it's a dual control mode, providing MMV
PAV proportional assist vent: Dragger 4; it adjusts PS level according to V, Elastance, RAW, & flow demand: good for pt with COPD and can combine w/ PAX and CPAP
VAPS Volume-assured pressure support: Stable Vt by using PS with VAV (volume assisted cycles), prolongs the I-time: Watch carefully!
PRVC Pressure regulated volume control: PIP kept lowest by changing peak flow & iTime according to RAW & C.
APC adaptive pressure control
VV+ Volume ventilation plus: Puritan Bennett 840, Dual mode = Volume Control + Volume Support
PCV Pressure controlled vent: Time triggered, Plateau Press created & maintained for cycle iTime **used for ARDS (must sedate) b/c only mandatory breaths dlvrd , then wean back to VC when can
APRV airway pressure release vent; Expiration occurs when high pressure is changed to low pressure. We set Phigh & P-low
Biphasic PAP Biphasic positive airway pressure; just means BiPAP
IRV Inverse ratio vent: iTime ↑ than eTime; for ARDS need this; 2:1 or 4:1; mean ↑; creates more PEEP. Reduces intrapulmonary shunting & ↑ oxygenation.
ATC automatic tube compensation: ↑ or ↓ flow according to tub size
NAVA Neurally adjusted volume assist: electrodes on diaphragm controls/stimulates diaphragm, checks RR; to wean pt w/spinal cord injury or head injury
HFOV High-frequency oscillatory vent: Hypoventilation managed by ↓ RR
Closed Loop system the input (pressure) is constant and the output (flow) is variable; Sustains pressure plateau; MMV, ASV, PRVC, PAV, VAPS, VA;
Role of vent during spontaneous mode (not a mode set on vent) 1) inspiratory flow to pt in timely manner; 2) flow adequate to fill pt inspiratory demand; 3) adjunctive modes (PEEP) to help pt spontaneous effort
Apnea Ventilation Safety feature within spontaneous mode; dlvrs Vt, RR, FiO2, and vent functions essential to pt
Difference of PS and PC iTime
Simple operating mode whatever you set on vent becomes the constant. ie: Set Vt, dlvd at constant flow
Indications PEEP refractory hypoxemia due to intrapulmonary shunting; ↓ FRC, ↓ Compliance
Physiologic PEEP Reduces threshold for alveolar opening; FRC ↑, enhances gas diffusion & O2
Complication PEEP ↓ venous return, ↓ CO, barotrauma, ↑ ICP, ↓ renal function & water metabolism
Indication BiPAP Prevent intubation, Chronic vent failure, restrictive chest wall disease, neuromuscular disease, nocturnal hypoventilation (apnea)
Indications CMV Tetanus seizures, complete rest, crushed chest injury, paradoxical chest wall movement
Complication CMV Prolonged sedation = vomiting, apnea & hypoxia, rapid atrophy b/c disuse of resp muscles
Indications AC Full vent support, minimize atelectasis
Advantages AC ↓ WOB, pt can ↑ Ve
Complications AC Hyperventilation
Indications IMV Mandatory vent, RR w/precise timing, Spontaneous breathing allowed in between
Complication IMV Breath stacking, air-trapping
Indications of ARDS PaO2 < 60 and FiO2 50% or greater
P/F Ratio
Indication Refractory hypoxemia FiO2 of 50% or greater
Target Pressure for BiPAP 5-7 ml/kg
VCV Volume Control: Dlvrs Vt, & PIP is variable, according to pt. We set Vt & if C ↑, Pressure ↓
PCV Pressure Control: If ↑ RAW & ↓ C, will ↓ dlvd volume. We set pressure & Vt is variable. Set iTime=plateau pressure. ↓RAW=↑Ve, iTime is constant. Don't mess with rate, it changes iTime; changes TCT, messes with volume
VS Volume Support: apneic pt. won't get breath needs backup PRVC or VV+
What is PEEP without a RR? CPAP
P-high Is inspiration = oxygenation
P-low Is expiration = ventilation
Normal P-high 6 ml/kg
Inverse Ratio means Creating another plateau trying to oxygenate; longer iTime
Why do we get auto PEEP? Air Trapping: not long enough to exhale
What is an oscillator? Decreases pressure, then frequency. SV; high rate range & 3-15 Hz
Advantages SIMV ↓ MAP, need PS to help with Vt
What is auto mode? On the Servo i vent
Indications PCV ARDS, stiff lungs, respiratory disease
Created by: Beccaboop