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Icm > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What is the definition of weaning delay

A

Failing more than three spontaneous breathing trials
Needing greater than 1 week of mechanical ventilation following the first SBT
Need for more than 2 weeks of ventilation without a resp factor prevention delay or for 3 weeks -> failure

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2
Q

What are the principles behind a successful wean

A 
Adequate rest
Gradual reductions in support
Sprints 
Downsizing of tranchoestomies 
Periods of cuff down deflation
Optimising sedation holidays / breaks
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3
Q

Describe an obstructive flow loop

A

Dipping pattern to expiratory loop with prolonged expiratory phase

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4
Q

Describe a restrictive flow loop

A

Reduces volume with a grossly normal shape

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5
Q

Describe a fixed upper air ways obstruction flow loop

A

Flattened inspiratory and expiratory traces

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6
Q

What are the causes of interstitial lung disease

A

Inhaled- asbestosis, hypersensitivity pneumonitis (dust), silicosis

Drugs- amiodarone, methotrexate

Connective tissues - RA, SLE

Infection- TB, PCP, atypical infection

Malignancy- Radiotherapy, lymphagitis carcinomatosis

Idiopathic- sarcoidosis, IPF, interstitial pneumonia

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7
Q

Pharmacological Treatment options for a PE

A

Low molecular weight heparin
Unfractionated heparin
Fondaparinux

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8
Q

Features suggestive of massive PE

A

Blood pressure <90
Or a drop of >40 mmhg
For at least 15mins with no other cause (arrhythmia/ low GCS/ shock)

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9
Q

What is the oxygen index equation

A

Fio2 x 100 x mean airways pressure / pao2

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10
Q

Life threatening asthma fees

A 
Altered consciousness
Arrhythmia 
Hypotension
Cyanosis 
Silent chest 
Poor rr effort
pefr <33%
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11
Q

Treatment of asthma

A 
Oxygen 94-98% sats 
Beta 2 agonists 
Ipratropium bromide
Steroids 
Mgso4
Aminophylline
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12
Q

Ventilation strategies for dynamic hyperinflation

A 
Reducing the tidal volume
Shortening of the Inspiratory time -> increase I:e ratio 
Reduced RR
Reduce extrinsic PEEP
Disconnection and manual decompression
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13
Q

What is the purpose curb65

A

To assess severity and predict mortality

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14
Q

What parameters are in the curb 65

A

Confusion mini mental <9
Urea >7
Rr > 30
Bp systolic <90 or diastolic <60

> 65 yrs

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15
Q

What are the 3 different types of effusion

A

Uncomplicated - sterile
Complicated - bacteria without pus PH <7.2
Empyema - ph >7.2

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16
Q

What are the indications for niv in acute exacerbation of copd

A

Ph <7.35
And
Pco2 > 6.5
After medical management

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17
Q

Contraindications to NiV

A 
Not indicated
Patient refusal
Facial deformities 
Facial burns / injuries 
Fixed upper air ways obstruction
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18
Q

Complications of NIv

A 
Nasal bridge ulceration 
Mucosal drying 
Gastric distension
Sinusitis
Anxiety
Pneumothorax 
Hypotension 
Raised icp
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19
Q

What is the basic preparation for spirometery

A

No smoking 24 hours
Avoid exercise and large meal prior to the test
Record patients: age, ethnicity, height, weight

Prepare the one way mouth piece, nose clip and bacterial and viral filters and spirometer

Reconfirm consent. Tell the patient to sit, breath in to maximal inspiration and create a tight seal around the mouthpiece.
Blow into the device as forcibly as possible and as long as possible.

3/8 acceptable readings and best result recorded.

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20
Q

What is FVC

A

Forced vital capacity - total exhaled volume during a forced maximal expiration from maximal inspiration.

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21
Q

What is the meaning of fev1/ fvc?

A

The proportion of the forced vital capacity that is expired in 1 second

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22
Q

What is the clinical relevance of DLCO

A

Lung diffusion capacity for carbon monoxide is a surrogate estimate of the ability for oxygen to pass from the alveolar to the red blood cell

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23
Q

What is the meaning of the tlc

A

Total lung capacity is vital capacity and residual volume

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24
Q

How is copd graded

A

Gold 1: FEv1 ≥ 80% predicted

Gold 2 : FEV1 50-79%predicted

Gold 3 : FEV1 30< 49% predicted

Gold 4 : FEV1 < 30% predicted

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25
Q

What is vital capacity

A

Tidal volume
Insp reserve volume
Expiratory reserve volume

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26
Q

What factors used in judging if someone ready for extubation.

A 
Lung pathology resolved 
Cough
Low o2 and settings
Haemodynamic stability 
Alert
Chest wall strength
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27
Q

What is rsbi

A

Rr/ tidal volume in l

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28
Q

What rsbi suggests ready for extubation

A

<105 80% chance successful

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29
Q

Describe the anatomical boarders of the triangle of safety

A

Lateral boarder pec major
Lateral boarder lat dorsi
5th intercostal space/nipple line
Axilla base

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30
Q

Where do you insert an apical chest drain

A

Second intercostal space mid clavicular line

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31
Q

What is a flail chest

A

fractures or 2 or more adjacent ribs

  • 2 or more places
  • paradoxical chest movement
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32
Q

What causes and increase in plateau pressure

A

Reduction in compliance

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33
Q

What causes an increase in peak airway pressure but bit plateau pressure

A

Airways resistance increase

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34
Q

In volume support ventilation what triggers the end of the breath

A

Reduction in inspiratory flow by a present proportion

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35
Q

What is lights criteria

A

Pleural protein to serum >0.5
Pleural ldh to serum >0.6
Pleural LDH > 2/3 normal

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36
Q

How is pleural albumin concentration used to determine transudate or exudate

A

Serum albumin - pleural albumin < 1.2 g = exudate

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37
Q

Empyema ph on pleural fluid

A

<7.2

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38
Q

What is the definition of compliance

A

Change in lung volume per unit change in pressure

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39
Q

What is the definition of static compliance

A

The compliance when there is no gas flow- end Inspiratory hold manoeuvre

40
Q

What is the definition of dynamic compliance

A

Measured during breathing cycle

Tidal volume / Peak pressure - peep

41
Q

Which should be high dynamic or static compliance

A

Static compliance is higher than dynamic

This is because you hold the insp cycle and normally your peak is higher than plateau pressure therefore it will be lower value

42
Q

BTs severe asthma features

A

Pefr 33-50
Rr >25
Hr >110
No complete sentences

43
Q

Bts life threatening

A 
Altered consciousness
Exhaustion
Arrhythmia
Silent chest 
Sats 92%
Po2 <8
Normal co2
Pefr <33%
44
Q

What is the oxygen content equation

A

Do2 (oxygen delivery) = cardiac output X arterial content of o2

Arterial content of o2= (Hb x sats x 1.39) + (0.003 x pa02)

45
Q

What is dead space

A

Part of the respiratory tract that does not contribute to gas exchange- anatomical or physiological (blocked or underperfused alveolar )

46
Q

What is the Berlin criteria

A

Timing : within a week of an insult
Imaging: bilateral opacification in keeping with oedema
Origin of oedema: not be explained by cardia failure
Moderate to severe hypoxia: PF ratio with peep 5 giving PF of < 26.6

47
Q

Mechanism of inhalationary injuries

A

Heat - oedema, erythema and ulceration

Toxin- chloride, ammonia etc causing damage with pH or free radicals

Hypoxia- environmental consumption of oxygen.

48
Q

Pathophysiology of inhaled lung disease

A

Exudative phase - neutrophil influx macrophage activation increase permeability decreased surfactant

Fibrotic phase - collagen deposit and fibroid get alveolitis

49
Q

Carbon monoxide inhalation mechanism hypoxia

A

250 time binding affinity to Hb than o2
Left shift
Cytochrome oxidase system is inhibited - tissue hypoxia

50
Q

Cyanide inhalation pathophysiology

A

Cyanide binds to ferric ion on cytochrome oxidase blocking aerobic metabolism

Therefore lactic acidosis

51
Q

Trratment cyanide inhalation

A

Hydroxycobalamin
Amyl nitrate
Sodium thiosulphate

52
Q

Define asthma

A

Chronic disease of the airways associate with hyper reactivity and inflammation.

Mucosal oedema
Increased sputum
Bronchospasm

Widespread airflow obstruction.

53
Q

How can you quantify dynamic hyperinflation from asthma

A

Quantify the intrinsic peep by an expiratory hold - enabling the expiratory alveolar pressure to equilibriate with the upper air pressure

Measured pressure - Peep delivered = intrinsic peep

54
Q

Define HAp

A

Pneumonia acquired more that 48 hours following admission

More likely to be gram negative organisms with higher rates of resistance

Psa, Kleb e.coli

55
Q

Common bacteria in cap

A

Strepto pneumonia
Haem influenza
Mycoplasma
Legionella

56
Q

What is in curb 65

A 
Confusion 
Urea > 7 
Resp rate  > 30
bp < 90
Age > 65
57
Q

Transudate pleural effusion
Protein level
And cause

A

Protein < 30

Increased hydrostatic pressure
Heart, liver and kidney failure
Hypothyroid

58
Q

Exudate pleural effusion
Protein level
And cause

A

> 30

Increased capillary permeability 
Pulmonary infection 
Malignancy
Connective tissues - RA  SLE 
Pancreatitis
59
Q

Aetiology broncopleural fistula

A 
Post pulmonary surgery
Post pneumonia
Cancer (bronchial)
Trauma
Ards
60
Q

Management bronchopleural fistula

A 
Ventilation strategy:
Avoid positive pressure
Oscillation 
Ecmo
Dlt 
Closure:
Stent
Glue 
Bronchial blocker
Lobectomy
61
Q

Define copd

A

Progressive inflammatory lung disease, characterised by expiratory airflow limitation due to obstructive bronchiolitis and or parenchymal destruction.

62
Q

Spirometery needed to define copd

A

Post dilator FEV1/ FVC < 0.7

63
Q

Indications for ITU in copd

A

Persistent worsening of hypoxia with Ph < 7.25 despite o2 and NIV

64
Q

Which patients should be considered for LToT

A

Stable chronic copd and pao2 <7.3

Or

<8 and oedema/ polycythemia / pulmonary hypertension

65
Q

Consequences of intrinsic peep on physiology

A

Decreased venous return
Increased pulmonary vascular resistance
Barrotrauma

66
Q

Define ICU acquired weakness

A

Clinically detected weakness where there is no other aetiology
Spectrum of critical illness myopathy, critical illness polyneuropathy or critical illness neuromyopathy

67
Q

Features of ICU acquired weakness

A

Symmetrical flaccid tetraparesis with sparing of the Facial muscles

68
Q

In the Cim and CIPN of ICU acquired weakness what do the nerve conduction studies show

A

Cim : normal

CIPN: decrease compound muscle action potentials and sensory action potential, normal velocity

69
Q

Anatomical changes post pneumonectomy

A 
Space fills with air 
Often ICD but not on suction 
Raised hemidiaphragm
Mediastinum shifts towards space
Hyperinflation remaining lung
4months- complete opacification 
Lung volume and dlco reduce < 50%
70
Q

Complications post pneumonectomy

A 
Haemothorax
Chylothorax 
Pulmonary oedema 
Bronchopleural fistula 
Post pneumonectomy syndrome - sob, infection, Stridor
71
Q

What is cpet and what is a bad scores

A

Quantification of cardio respiratory reserve by determining the anaerobic threshold

Cycle, measure inspired and expired gasses BP and ecg
AT < 11 is associated with adverse risk

72
Q

Considerations is obesity in critical care

A 
Increase in difficult airway 
Perc trache difficult 
Raised HD, reduction frc 
Reduced chest wall compliance 
IV Access 
BP cuff
Increased VTE 
Insulin resistance 
Increased volume of distribution
73
Q

What is the stop bang

A

Snore loudly
Tired in the day
Observed you chocking in sleep
Pressure BP high

Bmi
Age > 50
Neck large
Gender - male

74
Q

What is the mallampati score

A 
1-4 
1- entire uvula 
2- uvula masked by tongue
3-only soft palate 
4- only hard palate
75
Q

What is the interinsisor

Gap

A

Distance in cm between the upper and lower incisor

Less than 3.5 cm is poor

76
Q

What is thyromental distance

A

Chin to Adam’s Apple with full extension and mouth closed

Below 6 cm is difficult to fit blade in.

77
Q

What is the upper lip bite test and jaw protrusion.

A

Upper lip bite test 1-3 (3 unable to bite)

Jaw protrusion grade a- c (c can’t meet upper teeth)

78
Q

What sternomental distance indicates difficult airway

A

< 13cm

79
Q

Lobes of the left lung

A

Left main bronchus - left upper and left lower

Left upper has 2 divisions - upper (which had posterior and anterior) and lower ( inferior and superior)

Left lower has 3 divisions- superior, anterior and posterior.

80
Q

Lobes of the right lung

A

Right upper has 3 segments (anterior, apical, posterior)

Right main bronchus becomes bronchus intermedius

Right middle has 2 ( medial and lateral)

Right lower has 1 superior and 4 basal

81
Q

What strategies for ARDS have evidence

A

Proning - 16hrs 5/7 decreases mortality
Low TV with 6mls/kg and pp<30 decrease mortality
Ecmo decreased mortality in mod/ severe

Paralysis- possibly in moderate ards
High peep - > 15 decreases at electro trauma

82
Q

Define primary pneumothorax

A

< 50
Non smoker
No underlying lung disease

83
Q

Treatment of primary pneumothorax

A

Aspirate if > 2cm abs SOB

Send home if < 2cm

84
Q

Treatment of secondary pneumothorax

A

1-2 cm - aspirate
Consider HF for 1cm
> 2 or breathless then ICD

85
Q

Define massive PE

A

Acute pe with

Hypotension. < 90 for 15mins
Pulseless
Or
Brady

86
Q

Treatment options of PE

A

Anticoagulation with UFh

Reperfusion - thrombolysis embolectomy

87
Q

Anatomical and physiological dead space definition

A

Anatomical - air ways, trachea and proximal bronch

Physiological- vq miss match

88
Q

How does HFNC meet inspiratory needs

A

The high. Flow rates exceed patients Inspiratory flow and therefore entrain less air and deliver the intended fio2

89
Q

Components of high flow

A 
Gas blender
Flow meter
Corrugated tubing
Sterile water
Heated breathing circuit
Canula
Heater and humidifier
90
Q

Starting pressure NIv

A

iPap 10

Epap 4

rR 12

91
Q

Define double lumen tube

A

Bifurcated tube with separate tracheal and endobronchial lumens

92
Q

Size of double lumen tube

A

37 female

39 male

93
Q

How to size a double lumen tube

A

12+ height /10cm

94
Q

Indications double lumen tube

A

Prevent damage or contamination of healthy lung

Control distribution of ventilation

Facilitate one lung lavage

Surgical access

95
Q

Insertion of double lumen tube

A 
Check cuffs
Lubricate
Insert stylet
Watch with laryngoscopy beyond vocal cord
Remove stylet
Turn 90 degrees
Hit resistance or desired depth
96
Q

Confirmation of double lumen tube position

A 
Inflate tracheal
Ventilate-> co2 / auscultation 
Clamp tracheal 
Inflate bronchial -> ventilation 
Release clamp

Bronch to confirm

97
Q

What is the triangle of safety

A

Lateral edge of pec major
Lateral edge lat Dorsi
5th intercostal space
Base axilla

Icm (16 decks)

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