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Patient Managmenet 2

Ventilator Circuit basics, modes of mechanical ventilation, etc

QuestionAnswer
What is the humidity temperature range for humidification? 31-35 degrees celsius
How much dead space does the HME create? 500-100 ml deadspace
If you have a tidal volume of less than 400 the tidal volume goes directly to active humidity
What are contra indications for the HME? presence of thick, copious, bloody secretions. Can create resistance. VTe is less than 70% of inhaled Vt or there is no ET cuff. Temperature below 32 degrees celcius. Spontaneous VE is greater than 10 L/M Aerosolized medication is given. A very small
In order to do the leak test on the MA1 the following settings should be used. Vt-200 ml Rate 12 bpm flow 40 LPM Pressure MAX All other parameters off
To perform the leak test you should allow the ventilator to trigger occluding the wye and exhalation side of the circuit Then, observe the pressure manometer and the pressure should plateau and hold
Lost volume is gas volume that does not reach the patient
What can cause lost volume? small circuit leaks gas leak at ETT cuff Tubing compliance or system compressibility
Lost volume is not a concern when it is less than 5% of the VT
What is the compression factor for a neonatal circuit? 1 ml/cmH20
What is the compression factor for a pediatric circuit? 2 ml/cmH20
What is the compression factor for an adult circuit 3 ml/cmH20
How do you find the circuit compression factor? (Cfac) Put in the preset setting and occlude the wye only. Observe the PIP and exhalved VT. Calculate by exhaled Vt/PIP
In order to calculate compressible volume set the ventilator to appropriate patient settings and attach to patients airway. Observe PIP and spirometer.
In order to then calculate the compressible volume (lost volume) Circuit Compression Factor * (PIP-PEEP)
The final step is to find the patients corrected Vt by exhaled VT-Compressible volume
Tubing compliance (Ct) is now measured and corrected on most newer vents
What are causes of the high pressure alarm going off? Coughing secretions kink in tubing pneumothorax
What are causes of low pressure alarms? circuit disconnection cuff leak/tube too small chest tube leak Open lavage Port
In control mode the ventilator delivers a machine (preset) breath at a specific time interval
In control mode the ventilator controls rate, VT or pressure and the patient does not have control
The control mode of the ventilator should only be used when the patient has been properly medicated
What are indications for control mode? To provide full ventilatory support (patient fighting the ventilator, tetanus/seizures, complete rest, crushed chest injury/paradoxical movement)
What is a complication of the control mode? Patient is ventilator dependent
In Assist Control Mode the patient can control the rate, but the Vt or Pressure is controlled by the ventilator. A minimum rate is set
What are indications of assist control? To provide full ventilatory support
What are the advantages of assist control mode? Patients can control rate which controls VE, Low WOB
What are complications of Assist control mode? Hyperventilation (stress, anxiety, pain)
For Intermittent Mandatory Ventilation the ventilator delivers a set number of breaths at a set tidal volume or pressure but allows the patient to breath spontaneously in between at their own Vt.
What is the indication of IMV mode? To provide partial ventilatory support (post-op patients, weaning)
What are the advantages of IMV? Maintains muscle strength Facilitates Weaning Less positive pressure Reduces V/Q mismatch
What are complications of IMV Mode? stacking of breaths muscle fatigue increased work of breathing
What Ventilator Settings are prescribed by the physician? Mode, VT, Fi02
What are the basic ventilator settings/alarms? mode, Vt, Rate, Flow,Fi02, I:E ratio, Sensitivity, FIO2 Alarm, High pressure alarm, Low pressure alarm, Low exhaled VT alarm.
What is the basic setting for VT? 10 ml/kg
What is the basic setting for rate? 8-12 breaths per minute
What is the basic setting for flow? 40-60 LPM
What is the basic setting for Fi02? 40%
What is the basic setting for I:E 1:2; 1:3
What is the basic setting for sensitivity? Pressure trigger (-2 cm H20) Flow trigger (2-4 L/Min)
What is the alarm setting for fi02? +/- 5%
What his the high pressure alarm setting? 10-15 cmH20 above PIP
What is the low pressure alarm setting? 10-15cmH20 below PIP
What is the low exhaled Vt setting? 100 mL below exhaled vT *consider spontaneous VT *Check for leak
Flow will affect PIP
For COPD patients you may choose to set the flow at 50-60 LPM
Positive End Expiratory Pressure increases the end-expiratory pressure to a value greater than atmospheric
What are the indications of PEEP? TO improve FRC Improve oxygenation
What are complications of PEEP? worsens the effects of positive pressure, bauraotrauma, airtrapping, pneumothorax, decrease invenous return, decreased urine output
What is the companion to PEEP? COntinuous positive airway pressure
CPAP is applied to spontaneous breaths
PEEP is used to help with oxygenation
What is the PEEP/Fi02 Rule? If the patient is on greater than 60% fi02 without PEEP, add it in
Before ventilators were designed that incorporated PEEP systems inside the unit PEEP was added externally by placing a device on the expiratory limb of the patient circuit
What are examples of external PEEP devices? Underwater Seal, Water Column, Boehringer Valve, Spring loaded valve (Down's Valve)
What is the pro of the underwater Seal PEEP system? Low cost, non invasive
What is the CON of the underwater Seal PEEP System? loss of peep with evaporation Bubbling
What is the emerson Water Column? It is similar to the underwater seal but it's diaphram reduces bubbling
The Boehringer Valve has a ball that creates pressure
What is the pro of the Boehringer Valve? No H20 is needed
What are Cons of the Boehringer Valve? Must remain upright. PEEP only goes to a certain value.
The Down's Valve and Spring valve are similar in that they both contain a spring
What is the pro of the spring/downs valve? They work in any position
What is the con of the spring/downs valve? There is a limited amount of PEEP that can be reached
What is the PEEP that can be achieved with the down's valve? 2.5-15 cm H20
What is the PEEP that can be achieved with the screw down valve? 0-20 cm H20
What is the formula to calculate Inspiratory Time (Sec(? Vt/Flow (Flow must be converted to Liters per second) Vt must be in Liters.
What is the calculation for RCT? 60/Respiratory Rate
What is the calculation for Et(Sec) RCT-I time
What is the calculation for I:E ratio? IT/IT:Et/IT
What is Peak Inspiratory Pressure? The amount of pressure required to deliver the Vt overcoming the airway resistance.
What is PIP used for? to calculate dynamic compliance which is a reflection of lung compliance and airway resistance.
The Ppl (plateau pressure) is caused by inspiratory hold and stops flow.
The Ppl corresponds with Phase 2 of the respiratory cycle
The Ppl is the amount of pressure required to maintain lung inflation in the absence of airflow.
How do you obtain the Ppl? Inspiratory Hold which will lengthen the I time.
Ppl is used to calculate static compliance which is a reflection of lung complaince.
What are other uses for an inspiratory hold? Improve oxygenation, administer MDI therapy.
Resistance holds no bearing on plateau pressure
What is Cdyn? Reflects lung compliance and/or airway resistance.
How do you calculate Cdyn? Corrected vT/(PIP-PEEP)
What is the normal values for Cdyn? 30-40 ml/CmH20
What does Cstat do? Reflects lung compliance only and cannot reflect airway reesistance because there is no gas flow.
What is the formula for cStat? corrected VT/(Ppl-PEEP)
Compliance is equal to Change in V/ Change in P
Compliance reflects the degree of lung volume per unit of pressure
In a normal healthy patient Cstat is 70-100 ml/cm H20
In a male on a ventilator Cstat should be about 40-50 ml/cm H20
In a female on a ventilator Cstat should be 35-45 ml/cmH20
cL is the abbreviation for lung compliance
What are conditions that decrease lung compliance? Atelectasis ARDS Pneumothorax
When there is a decrease in lung compliance PIP and Ppl both increase. This in turn decreases static and dynamic compliance.
An increase in airway resistance may be due to bronchospasm kinking/biting of ETT Airway obstruction
With an increase in Airway resistance there will be an increase only in the PIP. Dynamic compliance will be decreased only.
Airway resistance obsructs airflow.
Airway resistance is increased when the diameter or patency of the airway is reduced
Airway resistance can be caused by changes inside the airway (retained secretions), in the wall of the airway (inflammation), or outside the airway (ie, tumors)
What is normal RAW on an unintubated patient? .6-2.4 cmH20/L/Sec
What is the normal Raw on an intubated patient with a flow of 30 L/Min? 6 cmH20/L/SeC
How do you calculate Raw(cmH20/L/Sec) PIP-Ppl/Flow(l/s)
In order to calculate RAW flow must be in Liters per second and constant. It is the limit variable.
Waveforms are graphical representations of the control or phase variables in relation to time.
Observation and assessment of waveforms during mechanical ventilation can provide useful information, such as inadvertant PEEP, WOB, resistance and compliance changes, patient/ventilator dyscynchrony, and leaks
The descriptors used to describe each waveform are based upon their respective shape
What is the function of the expiratory retard and sigh controls on the MA-1? The expiratory retard is a PEEP knob. The sigh controls are to give a large VT breath.
The sources that illuminate the lights on the control panel of the MA 1 are Assist Pressure Ratio Sigh Oxygen
What is a range for Ppl to use on graphics? 0.1-1.3 seconds and must correspond with Vt and Flow
Adding an inspiratory hold or plateau will do what to inspiratory time? increase
Increasing the inspiratory rate on the MA-1 will do what to I time? NOt change
Increasing tidal volume on the MA-I will do what to the Inspiratory time? increase
Increasing the respiratory rate on the MA-I will do what to the I:E ratio? decrease
Increasing the respiratory rate on the MA-I will do what to the peak pressure? NOt Change
Increasing the tidal volume on the MA-I will do what to the peak pressure? Increase
Increasing the flow rate on the MA-I will do what to the peak pressure? Increase
In the presence of normal compliance and resistance an MA-I produces what kind of wave form? Flow wave form
What three factors impact I time? Rate, VT and VE?
Created by: kparkerlehman