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RTT 213 - Ch. 13 MV

Ch. 13 - MV - Methods to Improve Ventilation and Other Techniques

what are the first 30-60 minutes following initiation of ventilation spent evaluating? vital signs, BS, vent parameters, CL/RAW, artificial airway, documenting pt response to therapy (vent graphics)
once the initial assessment is performed, the ____ results are evaluated; what are the 2 parts of this? ABGs; 1. ventilation (pH,PaCO2,HCO3) 2. oxygenation (PaO2,SaO2,CaO2,DO2)
what are the 3 factors that can alter PaCO2 during MV? 1. total ventilation 2. dead space 3. CO2 production
a change in _______ __________ will often be needed when a pt is first placed on MV. minute ventilation
what determines when the pt needs full ventilatory support? when the pt needs the ventilator to provide all the energy necessary to maintain effective alveolar ventilation
what determines when the pt needs partial ventilatory support? MV when machine rates are <6 breaths/min, pt participates in WOB to maintain effective alveolar ventilation
what are the initial settings for FVS? PaCO2 - 45 or normal for pt; rate - 8 or more breaths/min; VT - 6-12 mL/kg
what are the initial settings for PVS? rate - <6 breaths/min
what are causes of acute resp acidosis in the non-ventilated pt? 1. parenchymal lung problems 2. airway disease 3. pleural abnormalities 4. chest wall abnormalities 5. neuromuscular disorders 6. CNS
whether the pt is on VV or PV, increasing ______ __________ will decrease PaCO2. minute ventilation
what are the recommended guidelines for VT and plateau pressure? VT: 8-12 mL/kg IBW; Plateau: <30 cmH2O
what is the tidal volume for normal lungs? COPD? neuromuscular disorders? asthma? closed head injury? ARDS? CHF? normal: 10-12, COPD: 8-10, neuromuscular: 12-15, asthma: 4-8, closed head injury: 8-12, ARDS: 4-8, CHF: 8-10
in PCV, what also may increase if inspiratory time is increased? volume delivery, without increasing pressure
pressure determines ________. volume
what are common causes of respiratory alkalosis? hypoxia (w/ compensatory hyperventilation), parenchymal lung disease, meds, MV, CNS disorders, anxiety, metabolic problems
in MV pts, ____________ is often the cause of respiratory alkalosis. hyperventilation
how would you correct respiratory alkalosis during VV? decrease ventilation during VV by decreasing f, and VT if necessary (PV: f, then pressure)
what might reducing the VT to <8 mL/kg result in? atelectasis
what would be the 2 approaches in correcting respiratory alkalosis during spontaneous efforts if all else fails? 1. change mode (SIMV/PSV) 2. sedate pt (control breathing)
when might sedation be needed? 1. extreme agitation 2. increased WOB 3. dyssynchrony
what are common causes of hyperventilation? hypoxemia, pain, anxiety, fever, agitation, dyssynchrony
how do some pts with brain enjery tend to breathe? high VT and f (CNS lesion)
what should treatment of metabolic acidosis and alkalosis focus on? identifying metabolic factors that can cause these acid-base disturbances
pts in apparent respiratory distress may present with _________ ________. metabolic acidosis
during metabolic acidosis, what is the range of pH and HCO3? pH: 7.00-7.34, HCO3: 12-22
what are metabolic acidosis pts at risk of developing? respiratory muscle fatigue
in this situation, MV is indicated to meet the minimum goal of compensated __________. hypocapnia
what are causes of metabolic acidosis? 1. ketoacidosis 2. uremic acidosis 3. loss of HCO3 (diarrhea) 4. renal loss of base 5. overproducation of acid 6. toxins
what is the treatment of metabolic acidosis? effective therapy to deal w/ acidosis,; assessing need for reversal using alkaline agent
what is the controversy regarding metabolic acidosis? 1. benefit of using alkalinizing agents (HCO3 administration) 2. lowering arterial CO2
what is the range for pH and HCO3 in metabolic alkalosis? pH: 7.45-7.70, HCO3: 26-48
what are common causes of metabolic alkalosis? 1. loss of gastric fluid/stomach acids 2. acid loss in urine 3. acid shift into cells 4. lactact, acetate, citrate administration 5. excessive HCO3 loads
what treatment might be required in severe cases of metabolic alkalosis? carbonic anhydrate inhibitors, acid infusion, low HCO3 dialysis
metabolic alkalosis must be corrected BEFORE _____. PaCO2
what are causes of increased dead space? pulmonary embolism or low CO (low pulmonary perfusion), high PEEP
in the case of air-trapping (auto-PEEP), what may correct this problem? increasing the flow or decreasing I:E ratio
what can significantly improve gas exchange and help address the problem of air-trapping? reposition pt so disease lung receive minimal blood flow (independent position)
what is the normal ratio of dead space to tidal volume (VD/VT)? critical pts? 0.2-0.4; 0.7
what is a more common way to determine if dead space is changing? monitor ETCO2 (35-43), measure gradient between PaCO2 and ETCO2 (1-5)
with this way, what suggests an increase in dead space? decrease in ETCO2 and increase in PaCO2
metabolic rate and VCO2 are elevated in pts who have...? fever, burns, multiple trauma, hyperthyroidism, muscle tremors/seizures, agitation, multiple surgeries
what was iatrogenic hyperventilation used for? in pts with acute head injury and increased intracranial pressures
what might hyperventilation during the first few days following severe traumatic brain injury increase? cerebral ischemia, cause cerebral hypoxemia
_____ ___________ may be used for longer periods in situations in which increased ICP is refractory to standard treatment including sedation and analgesia, neuromuscular blockade, cerebrospinal fluid drainage, and hyperosmolar therapy. mild hyperventilation
who is at risk for ventilator-induced injury? pts w/ ARDS or status asthmaticus, COPD
_________ _________ has gained popularity as an alternative form of pt management. permissive hypercapnia (PHY)
what is PHY? deliberate limitation of ventilatory support to avoid lung overdistention and injury to lung
in PHY, _____ is allowed to be increased above normal and ____ is allowed to decrease below normal. PaCO2; pH
what is the pH range for pt who do NOT have renal failure or cardiovascular problems? younger pts? 7.20-7.25; even lower
during hypoventilation, _____ increases and _____ decreases. PaCO2; PaO2
increases in PaCO2 and decreases in PaO2 that occur in acute resp acidosis also cause a _____ shift in the oxyhemoglobin dissociation curve. right
what is important to provide for pts with ALI receiving permissive hypercapnia? sedation
extremely high levels of CO2 (>200) can result in an anesthesia effect also known as ___ ______. CO2 narcosis
CO2 is a powerful __________ of cerebral vessels. vasodilator
what are some contraindications of permissive hypercapnia? 1. head trauma/intracranial disease 2. intracranial lesions (ABSOLUTELY contraindicated) 3. preexisting cardiovascular instability
what are the circulatory effects of PHY? 1. decreased myocardial contractility 2. arrhythmias 3. vasodilation 4. increased sympathetic activity
what are common findings in pts receiving PHY? increased CO, normal SBP, pulmonary HTN
when is it particularly true to perform PHY with caution? cardiac ishemia, LV compromise, pulmonary HTN, R heart failure
when is PHY restricted? maximum target airway pressure and highest possible rates are used
what assessment is done in order to know suction is needed? breath sounds; visibly examine artifical airway
what are indications for suctioning? 1. coarse rhonchi/rales audible over large airways 2. visualization of secretions in ET
what color secretions do CHF pts produce? what shouldn't you do with these pts and why? thin white or pink frothy; suction; heart prob, not airway problem, worsens hypoxemia
what is the suction catheter length? 22 in (56 cm) - long enough to reach mainstem bronchus
what is the normal (and maximum) suction levels for adults, child, and infant? adult: normal -100 to -120, max -150; child: normal -80 to -100, max -125; infant: normal -60 to -80, max -100
how long should suctioning be? <15 secs
what are complications of suctioning? leak in system, suction off, bad connections, full collection canister, discomfort/anxiety
in pts with reactive airways, suctioning can result in ____________. bronchospasm
what can suctioning cause to the mucosal wall? hemorrhage, airway edema, ulceration
what are complications with suctioning associated with? duration, amount, size of catheter, oxygenation/hyperventilation before procedure done correctly
what are other common occurances during suctioning? cardiac arrhythmias, tachycardia, bradycardia, hypotension, hypertension
secretion removal is more critical in pts with _____ _______. small airways (small lumenal ETS)
what is the advantage to closed-suction technique? no disconnection from vent (reduces contamination)
who might benefit for with closed-suction technique? pts with specific disorders
______ ___ have been used for years to protect the airway from aspiration. cuffed ETs
what represents the majority of ETs used in the acute care setting today? high-volume, low pressure cuffs
what might result in VAP? bacterial colonization of the TBT
what are the reasons for silent aspiration and VAP? 1. injury to the mucosa 2. interference w/ normal cough reflex 3. aspiration of contamination 4. development of contaminated biofilm around ET
what is the percentage of VAP? 10%-60%
what has been developed to reduce the incidence of silent aspiration and allows for "continuous aspiration of subglottic secretions?" hi-lo evac ET (20 mmHg continuous suction)
why are continuous suction tubes not used with all pts? expensive
when is continuous aspiration of subglottic secretions (CASS) most effective? pts requiring intubation for >3 days
what are indications for using closed-suction catheters? 1. unstable pts on MV 2. hemodynamically unstable 3. desaturation pts 4. contagious infections 5. freq suctioning 6. inhaled gas mixture pts
ET suctioning for the removal of secretions is often preceded by instilled __-__ mL of sterile, normal saline into the airway, followed by ____________ and _____________ of the pt with 100% O2 via resuscitation bag or vent. 3-5; hyperoxygenation; hyperinflation
what is the intent of saline lavage? loosen secretions
what is the disadvantage of saline lavage? bacteria enter the airway causing nosocomial pneumonia
_____ __________ can increase the volume of secretions and potentially make airway obstruction even worse. saline instillation
what might saline instillation cause? irritation to airways, severe coughing episodes, bronchospasm
what is probably more effective than saline lavage for secretion thinning and facilitating suctioning? intratracheal lavage w/ acetylcysteine or sodium bicarbonate
what should be documented on a ventilator flow sheet after suctioning? amount, color, characteristic; breath sounds
___________ are by far the most common drug administered by aerosol to MV pts. bronchodilators
what are the most common methods used for administering aerosol? MDIs and SVNs
what are the 4 factors that must be considered when delivering aerosol to MV pts? 1. type of aerosol device 2. vent mode/settings 3. severity of condition 4. nature/type of med and gas used to deliver it
what are the drug deposition rates for aerosolized meds? 1.5%-3.0%
what is the mean mass aerodynamic diameter of aerosol particles produced by MDIs and SVNs? 1-5 um
__________ factors can affect aerosol delivery. ventilator
what are the general settings to use when given aerosol delivery? LOW flow rates, HIGH vts, LOW resp rates
what type of delivery of nebulized bronchodilators is more effective in COPD and RAW pts? intermittent delivery rather than continuous
what are factors that affect aerosol administration? larger ETs (better), heated humidifiers (bad), delivery gas
what may improve aerosol deposition in pts with asthma by reducing airflow turbulence? helium-oxygen mixture
what presents with fewer technical problems when used during MV? MDIs
which type has a greater aerosol delivery: in-line chambers and bidirectional spacers or elbow adaptors and unidirectional spacers? in-line chambers and bidirectional spacers
what are SVNs known to only deliver? mucolytics, antibiotics, prostaglandins, surfactants
what is a common method for delivery of aerosolized medications during MV? external SVN powered by a separate gas source (O2 flowmeter)
what type of ventilator comes equipped to power a small volume USN? Servo
the mass median diameter of particles produced by the nebulizer is ___ micrometers. 4.0
during NPPV, when does the greatest aerosol deposition occur? when the neb is placed close to the pt, the inspiratory pressure is high, expiratory pressure is low
what can be measured to monitor pt response to bronchodilators? lung mechanics, breath sounds, vital signs & SpO2, pressure-time curves, flow-vol/pressure-vol loops
what suggests an improvement following therapy? reduced PIP, reduced transairway pressure, increased PEFR, reduction in auto-PEEP
what are other methods routinely used to help clear airway secretions and improve the distribution of ventilation? postural drainage and CPT
what are the recommended positions for ventilated pts based on their findings? supine, 45 decgree rotation prone w/ left side up, 45 degree rotation prone w/ right side up, return to supine
what is another method for CPT because the prone position is difficult in MV pts? oscillating vest
___________ is a procedure used to visualize the bronchi. bronchoscopy
what are the 3 separate channels included in the flexible fiberoptic bronchoscopy? 1. light-transmitting channel 2. visualizing channel 3. open channel
what is bronchoscopy used for? inspect airway, remove objects, obtain biopsies, clear secretions, place devices in airway
_______ is sometimes administered 1-2 hours ahead of time to reduce secretion production and help dry the pt's airway so that it is easier to visualize. atropine
________ _________ is used during the procedure. conscious sedation
what are the agents used during conscious sedation? opioid analgesics; benzodiazepines
what is important in pts with artificial airways? size of the fiberoptic bronchoscope
what is the rationale for turning immobilized ventilated pts freq during the day? prevent pulmonary complications (atelectasis, hypoxemia)
________ ____ automatically turn the pt from side to side on a continuous rotation up to a 45- to 60-degree lateral position. kinetic beds
what two lung pathologies is positioning particularly important? ARDS and unilateral lung disease
what does the prone position do for ARDS pts? improve oxygenation and decrease degree of shunt
what helps distinguish pts who are responders from nonresponders of prone position? improvement of 10 mmHg in PaO2 within 30 mins
within lung tissue, the distribution of the interstitial water and intravascular blood and the anatomical configuration of the lung are all influenced by _______. gravity
in a supine pt, _________ _______ is higher in the dependent regions where blood tends to flow. _____ ______ formation is likely higher too. hydrostatic pressures; lung edema
what is an important difference between normal subjects and those with ARDS in the nondependent portion? ARDS pts have increased tissue mass
how does blood move from supine position to prone position? not well ventilated areas in supine to better ventilated areas in prone position (results: better V/Q ratio)
what does the prone position change? position of the heart/great vessels so they're no longer pressing on lungs
what is a side effect of prone positioning? facial and eyelid edema
what is the recommendation range of time in the prone position? 2-24 hrs
patient feeding by the __________ enteral route may reduce the risk of vomiting and aspiration associated with gastric compression caused by the prone position. transpyloric
what are some indications for the prone position? improve oxygenation in ARDS; pts who fail to respond to lung recruitment maneuvers; high inspired O2
what are the 2 methods that are typically used to manage the ventilatory status of pts with unilateral lung disease? 1. independent lung ventilation (2 vents/double-lumen ET) 2. lateral position, "good" lung down
________ positioning dramatically improves gas exchange by improving V/Q matching without causing any hemodynamic complications, thus potentially allowing a decrease in FiO2. lateral
how long are adult vent circuit corrugated tubing? pediatric circuits? 22 mm-diameter; 9-13 mm-diameter
what are the objectives for changing a vent circuit? 1. limit nosocomial infections 2. vent circuit in tact 3. clean circuit 4. minimize risks
what do must vent circuits use to humidify? HMEs (passive), heated passover or heated wick
during a patient-vent system check, what should be checked? the ventilator circuit and the water level in the humidifier
how can fluid input/output be monitored? comparing daily fluid intake with output and by measuring body weight daily
what is normal urine production? ______ is a urine output of less than 400 mL/day or less than 20 mL/hr and _______ is a urine output of more than 2400 mL/day or 100 mL/hr. 50-60 mL/hr; oliguria; polyuria
what are 3 reasons for a decrease in urine output? decreased fluid intake/low plasma vol; decreased renal perfusion; renal malfunction
what is one of the most common causes of sudden drops in urine flow, which can be quickly reversed by irrigating the catheter? blocked foley catheter
what are common causes of decreased urine production in critically ill pts? renal failure or malfunction
what is one of the primary problems in the vast majority of ICUs? no method for communicating w/ pts
what is one possible tool to use in discovering if pts experience dyspnea? visual analog or number intensity scale (brog scale during exercise test)
what is the approach to reduce pt distress and fear referred to as? pt-centered mechanical ventilation
what are the 2 questions therapists might pose to pts who are conscious and able to respond? 1. are you short of breath right now? if yes.. 2. is your shortness of breath mild, mod, or severe?
what is the average duration of pt transport (one way)? and the avg time spent at the destination? 5-40 mins; 35 mins
what are the 3 options available for providing ventilation during transport? 1. manual ventilation 2. transport ventilator 3. most current generation ICU vents can be used for transport
what is a major disadvantage of pneumatically powered ventilators? they consume large vols of O2 during operation
Created by: christa_2008