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RTT 213 - Ch. 13 MV
Ch. 13 - MV - Methods to Improve Ventilation and Other Techniques
| Question | Answer |
|---|---|
| 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 |
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christa_2008
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