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Interventions 3 > Adult Pt getting sicker Vent Strategies (Mod 4) > Flashcards

Adult Pt getting sicker Vent Strategies (Mod 4) Flashcards

1
Q

What should your vent goals be if the patient is unable to maintain adequate oxygenation or ventilation (or both)

A

Increase ventilator support must be increased while minimizing damage to the lungs

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2
Q

Advanced strategies for ARDS patients that are getting sicker

A

Lung protective ventilation (ARDSnet and Driving pressure)

  • APRV
  • Proning
  • Optimal PEEP
  • ECMO
  • Independent lung ventilation
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3
Q

Berlin definition of ARDS

A

Presence of pulmonary edema not explained by cardiac issues

  • Acute onset (1 week or less) w/bilateral opacities w/pulmonary edema aka “white out”
  • PF ratio < 300mmHg w/min of 5 cmH2O PEEP (or CPAP)
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4
Q

How could edema be managed

A

Furosemide (lasix)

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5
Q

ARDS mild severity

A

200-300

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6
Q

ARDS moderate severity

A

100-200

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7
Q

ARDS severe severity

A

<100

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8
Q

ARDS treatment strategies

A

Peeps and FiO2s that increase together (according to ARDSnet)

  • Low Vts; Start Vts at 6 and titration up; given that Plats are less than 30
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9
Q

Liquid ventilation

A

Lungs can be ventilated with liquids given there is enough oxygen content in it

  • used for divers; bc air compresses under pressure; liquids don’t (as much)
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10
Q

What is more important aspect when managing ARDS?

A

Driving pressure rather than the actual Vts

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11
Q

Driving pressure vs mechanical power?

  • why is mechanical power receiving more interesting recently?
A
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12
Q

Theory of Airway Pressure Release Ventilation (APRV)

A

As an elevated CPAP pressure (aids oxygenation) w/brief intermittent releases in airway pressure (aids in ventilation)

  • Flow wave forms are the reverse of normal; longer Tis than Tes
  • Basically CPAP w/a release
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13
Q

Add slides 14-20

A
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14
Q

Advantages of Airway Pressure Release Ventilation (APRV)?

A

Employs lung protective strategies

  • Easy to manipulate both MAP and I:E
  • Aids both oxygenation and ventilation
  • Considered a comfortable mode as the Pt can take a Spontaneous breath as they want
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15
Q

Disadvantages of Airway Pressure Release Ventilation (APRV)

A
  • Designed to be used with spontaneous breathing pts
  • May cause respiratory muscle atrophy if pt is apneic for prolonged periods
  • Dangerous if applied incorrectly
  • Vts scare physicians who aren’t familiar with the mode
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16
Q

What is the theory for the benefits of elevated CPAP pressure?

A

High PEEPs = High mean airway pressure; improving oxygenation (at a safe plat)

  • Responsible for recruiting the most difficult to recruit alveoli
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17
Q

What complication do you need to monitor in Airway Pressure Release Ventilation (APRV)?

  • hint; Thigh and Tlow
A

Ensure that air trapping associated with Airway Pressure Release Ventilation (APRV) less than 15%

  • deliberailty holding air, means that we are allowing air trapping/holding (even tho Tlow is set at 0, it won’t actually derecruit)
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18
Q

Are Vts set high or low during Airway Pressure Release Ventilation (APRV)?

A

Vts can be set higher IF compliance increases (lungs can expand more), but driving pressures should be set lower (they should also realistically drop)

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19
Q
A

RR needs to be ajusted when Thigh and Tlow are changed.

  • Remember TCT = 60/RR; so RR = 60/TCT bc TCT = Thigh + Tlow
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20
Q

What is the impact of changes in lung mechanics in Airway Pressure Release Ventilation (APRV)

A

Maintaining Tlow so we push air back into the the lungs back in at 75%???????????

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21
Q

In APRV, if compliances is low should Tlow be set higher or lower?

A

Set lower Tlow

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22
Q

Check everything before slide 21: We Finished APRV

A
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23
Q

What is the goal of Prone Positioning?

A

Goal is to improve oxygenation by creating better v/q matching (via reduced shunt)

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24
Q

Inclusion Criteria for Prone positioning?

A

Severe ARDS as evidenced by?

  • **A P/F Ratio < 100 while on FiO2 > 0.6
  • OI greater than or equal to 20
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25
Q

DO2 formula?

A
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26
Q

Oxygen Index formula?

A

(FIO2 x Mean airway pressure/PaO2) (x100 if you need to convert it back)

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27
Q

What are the respiratory benefits of using APRV?

A

Improved v/q matching and better gas exchange for a given volume (improves ventilation)

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28
Q

What are the cardiovascular benefits of using APRV?

A

Retention of the thoracic pump mechanism

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29
Q

How does APRV impact oxygenation?

A

Improved through better recruitment and surface area for gas exchange

  • allows for higher MAP while still at safe plats
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30
Q

What benefit does APRV provide regarding a patients neurological status; such as in delerium?

A

Reduced need of sedation

  • instead of RASS levels of -4 to -5 (that are often done to reduce metabolic rate-VO2 and VCO2) patient can be more alert…RASS -2
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31
Q

How does aid in oxygenation and ventilation?

A

Makes it easier to manipulate both MAP and I:E

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32
Q

What is the goal of Prone positioning?

A

Goal is to improve oxygenation by creating better v/q matching (via reduced shunt)

33
Q

Which why should a patient be turned for proning?

A

Towards the vent

34
Q

Patient position for proning?

A

Reverse Trendelenburg, 30 degrees if possible

35
Q

How long are patients proned according to AHS policy?

A

20 hours per day, 16 of which are continuous

36
Q

Criteria for discontinuation of proning?

A

FiO2 < 0.60 or OI< 20

  • Deterioration of pt status related to prone position
  • Proning has no improvement to status
  • Doctor says stop
37
Q

What is the purpose of ECMO?

A

An extrapulmonary form of support that can provide oxygenation and/or ventilation of the blood

  • Allows time for the lungs to recover from their acute injury
  • Can be used up to 10 days
38
Q

What are 2 types of ECMO?

A
  1. Venoarterial (VA): provides respiratory and hemodynamic support
  2. Venovenous (VV): provides respiratory support only
39
Q

When would ECMO be used in adults?

A

severe ARDS or severe asthma

40
Q

When would ECMO be used in neonates?

A
  • PPHN (primary, or associated with pneumonia, MAS, RDS)
  • CDH
41
Q

Ventilator settings for ECMO?

A

30-30-10-10 approach

  • FiO2 0.3
  • Plat <30
  • PEEP 10
  • RR 10
42
Q

ECMO risks?

A
  • Bleeding
  • Thrombosis
  • Infection
  • DIC
43
Q

Whats Nova Lung?

A

A membrane ventilator

  • provides arterio-venous extrapulmonary lung support
  • Relies on Pts blood pressure to drive the system aka BP is needed
  • uses simple diffusion to provide oxygenation and ventilation
44
Q

Whats Independent Lung Ventilation?

A

Uses a double lumen tube with a ventilator attached to each lumen; each lung is vented independently and either synchronously or asynchronously

45
Q

Synchronous independent lung ventilation (IVL)

A

RR of both lungs is kept the same or PEEP, VT, etc can be set independently

46
Q

Asynchronous independent lung ventilation (IVL)

A

Lungs are inflated 180 degree out of phase

47
Q

How do you use Esophageal pressure monitoring to calculate Transpulmonary Pressure (Ptp)?

A

Intrapulmonary pressure (Plat) - (PIP) Intrapleural pressure

  • Pes is often a surrogate for PIP when using a esophageal balloon to measure pressures
48
Q

What are the advantages of using a Esophageal monitoring to guide pressure settings?

A
  • Airway Pressure alone may be misleading
  • TPP offers a more accurate assessment of stress on the lung tissue
  • Customization of PEEP and VT settings is possible
  • Measurement of TPP is fairly non-invasive
49
Q

What are the disadvantages of using a Esophageal monitoring to guide pressure settings?

A
  • Relies on correct balloon position
  • ARDS is heterogenous; Pes may not reflect TPP in whole lung
  • Nobody knows how to interpret Pes in prone patients
  • Pes overestimates pleural pressure in well aerated lung tissue and underestimates in in dependent regions; may relocate VILI without reducing severity.
50
Q

What does airway pressure (Paw) reflect?

A

Pressure required to inflate both the lungs and chest wall

  • Paw = Palv during pause maneuvers
51
Q

What are the implications from the ventilator if Paw = Palv?

A

During pause maneuvers, it implies that

  • Plats are measured during an insp pause
  • Total PEEP is measured during an expiratory pause
52
Q

What does pleural pressure (Ppl) reflect?

A

Pressure in the pleural space

  • affected by increased intra abdominal pressure or decreased chest wall compliance
53
Q

What factors affect pleural pressures?

A

Increased intra abdominal pressure or decreased chest wall compliance

  • Obesity
  • Ascites
  • Ileus
  • Bowel edema
  • Post fluid resuscitation edema of ab tissue
54
Q

How can you measure pleural pressure?

A

Measuring esophageal pressure

55
Q

What does Transpulmonary Pressure (Ptp) reflect?

A

Pressure required to inflate the lung only

56
Q

Safety limit for Ptp?

A

Keep Ptp < 25 cmH2O during inspiration for lung protective ventilation

57
Q

What should you aim for Ptp settings?

A

Aim for a positive Ptp 0-10 cmH2O during expiration to prevent alveolar collapse.

  • realistically 2-10 cmH2O tho
58
Q

How is Ptp calculated?

A

Ptp = Paw - Pe

  • Pe is thought to reflect Ppl
59
Q

Insertion technique for Esophageal balloon?

A

Insert to 60cm…pull back 40cm

  • should see cardiac oscillations on the monitors
60
Q

Smallest catheter for a Esophageal balloon?

A

6 Fr

61
Q

How can you check Esophageal balloon placement?

A

Should see cardiac oscillations on the monitor

  • Can also push the belly as a check to see temp spike in pressure
62
Q

What factors affect Esophageal Pressures (4)

A
  1. Elastic recoil of the esophagus
  2. Esophageal muscle tone
  3. Pressure transmitted from surrounding structures
  4. posture
63
Q

What posture should patients with Esophageal balloons be in?

A

Supine

64
Q

What pressures affect Esophageal pressures?

A

Pleural pressure and mediastinal pressure

65
Q

What relationship does pleural pressure have with transpulmonary pressure (ptp)?

A

They have an inverse relationship;

  • Increased pleural pressures implies a decrease in Ptp (alveolar pressure)
66
Q

What factors would cause a increase in pleural pressure (and thus decrease Ptp)?

A
  1. Increase in intraabdominal pressure
  2. Decrease in chest wall compliance
67
Q

What is a Delta Ptp is a measurement of?

A

Lung stress

  • DeltaPtp= Ptp plat - Ptp peep
  • Lung stress = k x strain
  • K = 13.5 cmH2O (constant for specfic lung compliance)
68
Q

What lung strain is considered lethal?

A

Lung strain of 2

  • lung strain = Deltaptp/13.5
69
Q

What needs to be ensured throughout expiration to prevent alveolar collapse when using esophageal monitoring?

A

Positive peep, in this case we refer to transpulmonary pressure (Ptp) to be positive throughout expiration

70
Q

Why is the purpose of Inverse Ratio Ventilation (IRV) (inversed I:E ratio) like 2:1?

A

Purpose is to increase Mean Airway Pressure (MAP) to help increase oxygenation time

  • keeps lungs recruited, big risk of air trapping and have less exhalation time for CO2 clearance
71
Q

How does a inverse ratio, such as in APRV reduce shearing stress?

A

You reduce the shearing stress that occurs when lung units fully inflate then deflate.

  • The idea is that you cause less lung tissue damage by limiting how much each alveoli deflates then there is less pressure and stress needed to reinflate the alveoli.
72
Q

How do you measure spontaneous breaths?

A
  1. Measured Total MV - (set RR x Vt)
  2. Subtract total RR - Set RR
  3. Divide step 1 by spontaneous breaths (step 2 value)
73
Q

Mode switch example:

  • VC to PC
A

V in this example is Vt.

  • After calculating Compliance
  • Manipulate the Comliance formula to calc for whatever you need with the values goals provided (if there are any)
74
Q

What waveform will display auto peep?

A

Auto peep will be determined in the flow time scalar waveform…NOT the pressure scalar

  • Expiratory hold determines the amount of auto peep present
75
Q

In VC-CMV, which of the following changes would result in an increased Te?

  • Increase Te = Decreased Ti
A

Changes from decelerating waveform to square flow pattern

  • Increased flow (increased Te = Increased flow)
  • Decreased RR (TCT decreases, takes more time to cycle to next breath aka decreased RR = Increased Te) (remember Increased Ti = Decreased Te => risk of airtrapping)
  • Decreased Ti pause
  • Decrased I:E ratio
76
Q

What does no observable pausae at the end of inspiration mean?

A

No Ti pause means PIP > plat (doesn’t hit baseline)

77
Q

no observable pause sample

A
78
Q
A

Interventions 3 (19 decks)

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