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Respiratory Flashcards

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1
Q

Indications for Mechanical Ventilation

A
  1. Airway Support - threatened airway, impaired airway reflexes
  2. Respiratory Support - high FiO2 required
  3. Ventilatory Support - deep sedation, regulate CO2
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2
Q

Delivery of non-invasive ventilation

A
  1. High flow nasal O2 - humidified O2, 40-60L/min FiO2 up to 1.0.
  2. CPAP
  3. BiPAP
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3
Q

Advantages of HFNO

A
  1. Humidification - prevent epithelial injury, help secretions
  2. PEEP
  3. Greater FiO2 - less entrainment of atmospheric gas
  4. Reduced CO2 dead space - washout
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4
Q

CPAP

A
  • Continuous application of positive pressure throughout respiratory cycle
  • Nasal, facemask, hood
  • Better recruitment, improved V/Q
  • Cheap, well tolerated
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5
Q

BiPAP

A
  • Ventilatory support by difference between IPAP and EPAP
  • Facmask
  • ECOPD, prevent post-extubation respiratory failure.
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6
Q

PEEP

A

Pressure present in airway above atmospheric pressure at end expiration
Recruitment of alveoli and prevention of collapse (therefore reduced WOB)
Other physiological effects
- Improved pulmonary compliance
- Reduced venous return and preload
- Increased afterload and PVR
- Increased ICP by reduced venous drainage

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7
Q

Characteristics of ventilator modes

A
  • Control - pressure or volume
  • Cyclying - flow, time, pressure
  • Trigger - patient, machine
  • breath type - mandatory or spontaneous
  • breath sequence - mandatory, intermittent mandatory, spontaneous
  • synchronisation - synchronised, independent
  • guarantee - TV, MV, pressure
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8
Q

PCV

A
  • Pinsp, PEEP, Ti
  • VT depends on compliance
  • pressure rapidly delivered and held constant - square wave pattern
  • flow decelerates
  • pressure rapidly released in expiration
  • gas equilibrates between varying alveolar time constants
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9
Q

VCV

A
  • VT, PEEP, RR, flow pattern set
  • constant inspiratory flow - gradual rise in Pinsp
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10
Q

Pressure support

A

Pinsp, PEEP, expiratory flow trigger set

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11
Q

Ventilator cycling

A
  • Time - mandatory modes, insp and exp determined by time
  • flow - insp and exp commenced after sensing change in flow (patient attempts breaths)
  • pressure
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12
Q

Special modes

A

ASV - adjusts support based on patient requirements. support delivered in response to RR and effort
NAVA - neural assist - electronic activity from diaphragm, monitored via specialist NG tube
SIMV - time cycled mode mandatory breaths may be machine or patient triggered. pressure or volume controlled. spont ventilation permitted at varying parts of the cycle

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13
Q

APRV - Airway Pressure Release Ventilation

A

Advanced ventilatory mode
Maximises alveolar recruitment - used when alveolar recruitment felt to be possible
P-high, Thigh, Plow (0) and Tlow
CO2 release at Plow
breath spontaneously
extreme inverse ratio
Ads - recruitment, lung homogeneity, reducing in cyclical opening and closing of alveoli
disads - high local pressure, tachypnoea, rv dysfunction

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14
Q

Indications for proning

A

Critical care
- mod-severe ARDS Pf < 150 (< 48hrs into disease after IPPV optimised) PROSEVA trial
Theatre
- surgical access e.g. spine, posterior fossa

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15
Q

Contraindications

A

Absolute
- open chest, <24h post cardiac surgery, central ECMO cannulas, unstable spine
relative
- severe CVS instability, pregnancy, recent tracheostomy, significant trauma

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16
Q

Risks of proning

A

Instability
- airway dispalcement
- line displacement
- increased into abdominal pressure
- reflux and aspiration
Patient injury
- pressure sores
- brachial plexus
- periorbital oedema, chemises, blindness
Staff injury

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17
Q

How to prone

A

Pre-procedure
- MDT decision
- check with nurse in charge senior doctor re. timing
- ensure any procedures that require supine position carried out
- system assessment e.g. airway position, suction. 100% O2. stop non-essential infusions
- eye / nipple protection, remove anterior ecg stickers
- spigot and aspiration NG tube
Procedure
- minimum 1 airway and 2 each side
- pillows to chest, iliac crests, knees
- sheet over top and roll edges (Cornish pasty)
- slide away from ventilator
- turn to 90 degrees
- complete prone
post-procedure
- re-assess A-E
- check pressure areas
- complete positioning e.g. swimmers, revers trendelenburg
- 2-4 hourly head turn and arm change
- document

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18
Q

conscious proning

A

covid. if fio2 > 28% or more than basic resp support
position change every 1-2 hrs - fully prone, right recumbent, sitting up 30-60 degrees, left recumbent

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19
Q

Types of extra-corporeal life support

A
  • VV-ECMO
  • VA-ECMO
  • AV-ECMO (rare)
  • ECCO2R
  • Cardiopulmonary bypass
  • VAD
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20
Q

VV-ECMO concept

A

Gas exchange in native circulation failed
an oxygenator incorporated into extra-corporeal circuit
oxygenation determined by circuit flow rate and post-oxygenator oxygen content. increased by increasing flow rate
co2 diffuses out through oxygenator determined by sweep gas flow rate. CO2 more soluble, diffuses more readily and maintains diffusion gradient. clearance therefore related to sweep gas rather than blood flow
conventional ventilation reduced to rest settings and allow healing of pathology
VV oxygenator flows limited to 5-6l/min (cannula size)

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21
Q

VV-ECMO indications

A

despite optimum conventional management: including trial of proning:
- hypoxaemic resp failure PF < 80
- hypercapnia resp failure pH < 7.25
“potentially reversible severe resp failure”
- ventilatory support as bridge to lung transplant
specific clinical conditions include
- severe ARDS
- BPF
- severe asthma
- thoracic trauma

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22
Q

VV-ECMO contraindications

A

Absolute
- anticipated non-recovery without a viable plan to decannulate
relative
CNS - haemorrhage, severe debilitating pathology, significant njury
refractory or established MOF
Haem - bleeding, inability to anticoagulant
IPPV > 7 days with plat pressure > 30 and fio2 > 90
older age

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23
Q

O2 delivery in VV ECMO

A

O2 content minimum 240ml.min
O2 delivery minimum 300ml.min
Arterial O2 is mixture of venous blood removed and passed through oxygenator and blood passing through lungs and is typically 80-90%

increasing circuit flow increased circuit:native and therefore total O2 content

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24
Q

Issues on VV ECMO

A

recirculation - post oxygenator blood returning to oxygenator and not systemic circulation (high venous saturations) more common with single lumen dual cannula access
hypoxaemia - increased VO2 e.g. sepsis, recircualtion. DO2 / VO2 5:1 increase flow
CO2 removal - sweep gas 1-9l/min in 100% O2
Chatter - partial venous cannula occlusion e.g. rhythmic ventilation, cough, valsava
suck down - intravascular volume restriction or cannula misplacement abrupt reducing flow to 1l/min with full pump speed - haemolysis, air embolism
high Paco2 - may be increased metabolic state, circuit problem, monitoring problem. can increase sweep gas flow

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25
ECMO emergencies
gas embolism - clamp return line, clamp drainage line, switch off pump, remove air using syringe at oxygenator port accidental decannulation - turn off pump, compress site, major haemorrhage, emergency recannulation circuit failure - change
26
VV-ECMO cannulas
Single lumen dual cannula - IJ - fem bicaval dual lumen single cannula - RA / IVC bifemoral Dual lumen single cannula improved mobility, needs fluoroscopy / echo guidance
27
Haemodynamics on VV ecmo
hypoxia, hypercarbia, acidosis lead to elevated PA pressures, rv dysfunction. implication - vv ECMO no direct haemodynamic support - need to manage conventionally - improved oxygenation and co2 clearance improves PA pressures, rv function, lv function - reduced thoracic pressures due to lower IPPV settings may also improve haemodynamics
28
Rest ventilator settings
recommended PEEP 10 Pinsp 25 rate 10 FiO2 as low as possible e.g. 30% CESAR / EOLIA settings
29
weaning ecmo
reduced circuit flow or reduce sweep gas FiO2 from 1.0 - 0.21 over hours - days assess ventilatory reserve
30
ECMO scoring systems
RESP - predicted survival on ecmo Murray - predicted mortality without ecmo RESP -22 to 16. Class I > 6 92% in-hospital survival. class V < -6 18% survival Murray - consolidation (quadrants on CXR) - compliance - P/F ratio - PEEP Severe > 2.5
31
ECMO trials
CESAR - improved outcomes from severe potentially reversible resp failure in those transferred to ecmo centre (not with use of ecmo) vs conventional - advocates transfer to specialist centre - Murray Score > 3 pH < 7.25 on optimum mx EOLIA - severe ARDS - VV-ECMO vs VCV (28% crossover) - no difference in 60d mortality.
32
What is ventilator weaning?
- slowly reducing ventilator support over time, increasing patients own ventilatory drive and extubation - may be minutes - months Simple: liberation from ventilator on first attempt (70%) Difficult - 2-7 days after initial assessment Prolonged - > 7 days
33
Clinical assessment of readiness to wean
- Initial pathology resolved - Patient condition optimised A: cough / reflexes satisfactory, secretions manageable, cuff leak present B: FiO2 < 40%, spont breathing, adequate strength, min PEEP C: stable D: obeying commands
34
Objective assessment of weaning
- RR < 30 - TV > 5ml/kg - FVC > 15ml/kg - MV < 15l/min Max inspiratory pressure < 30cmH20 (resp muscle strength) Rapid shallow breathing index = f/Vt (L) - some evidence for extubation with RSBI < 105 spring SBT P0.1/PImax > 0.3 = negative airway pressure from first 0.1s of occluded inspiration
35
Describe spontaneous breathing trial
- screen for readiness to wean - sedation hold - 30 min trial of T piece or minimal CPAP +/- PS - assessment of success or failure - if well tolerated consider extubation Criteria for failure B: RR > 35, SpO2 < 90%, high WOB C: HR > 140 or change > 20%, SBP > 180 or < 90 D: agitation
36
Problems with weaning difficulty
increased LOS, VAP, ICU-AW, mortality extubation failure and issues
37
Causes of failure to wean
Resp - secretions - poor cough - inappropriate ventilator settings - resistance from ETT - VAP / unresolved infection - Pulmonary oedema CVS - High myocardial workload - metabolic demand - unresolved CVS failure - fluid overload - anaemia CNS - delirium - weakness - pain Other pathology e.g. burns, malnutrition
38
Indications / advantages for tracheostomy
Indications - prolonged wean - longterm / home ventilation - airway toilet - upper airway obstruction e.g. laryngeal, VC Advantages - patient comfort - reduce sedation - improved mouth care - reduced airway oedema - ability to phonate / VC mobilisation - improved larnyngeal sensation / swallowing
39
Tracheostomy timing
multifactorial TRACMAN study early < 4d late > 10 days no difference in high risk prolonged ventilation
40
Percutaneous tracheostomy insertion
Pre-procedure - CI e.g. coagulopathy, high FiO2 - consent, MDT decision, NIC - team allocation - airway / bronch, sedation e.g. nurse, procedurist - equipment prep - positioning, USS - 100% O2, aspirate NG Procedure - asepsis, clean skin - xylocaine / adrenaline - airway person retracts ETT until cuff seen at cords - needle, with cannula, syringe, saline 1/2 or 2/3 tracheal rings - midline insertion aspiration until air - thread cannula, remove needle - check cannula with bronc - pass guide wire - check with bronchiole - scalpel incision then serial dilators - rhino dilator and leave in situ for a minute or two - remove and pass tracheostomy - inflate cuff, ensure ETCO2, remove oral tube - 2 x sutures and secure in place with tie post-procedure - CXR - wean sedation - document
41
Complications of tracheostomy
immediate - bleeding / haemorrhage - failure - pneumothorax / submit emphysema - aspiration - damage to local structures e.g. thyroid, RLN - loss of airway short term - deterioration in ventilation - infection - obstruction - displacement - tracheostomy's-innominate artery fistula long term - granuloma - VC dysfunction - dysphagia, dysphonia - stenosis
42
When can a patient be decannulated?
- improving trajectory - MDT opinion, nursing, physio - tolerating cuff deflation for prolonged period of time e.g. 24hrs - secretion burden manageable - minimal O2 requirement
43
Causes of restrictive lung diease
Pulmonary - ILD - ARDS - TB - Lobectomy Extrapulmonary - Resp centre = drugs, trauma - Neurological - polio, GBS - Neuromuscular = MG - Muscular = dystrophies - Thoracic wall = obesity, kyphoscoliosis, rib fracture - pleural = plaques, effusions, PTX
44
Types of interstitial lung disease
300 + conditions Known aetiology - Iatrogenic e.g. radiation - Extrinsic allergic alveolitis (hypersensitivity pneumonitis) e.g. farmers lung, pigeons lung - pneumonconiosis (lung injury from dust particles) asbestosis, silicosis - post-infectious Unknown aetiology - Idiopathic intersistial pneumonias - sarcoidosis - connective tissue disease - lymphangioleiomyomatosis (LAM)
45
Classification of idiopathic interstitial pneumonias (ERS)
Major - acute interstitial pneumonia (AIP) - idiopathic pulmonary fibrosis (IPF) - worst mortality - idiopathic non-specific interstitial pneumonia (NSIP) - cryptogenic organising pneumonia (COP) - respiratory bronchiolotisi ILD (RB-ILD) Rare - idiopathic lymphoid intersistial pneumonia Unclassifiable
46
Acute interstitial pneumonia
progressive hypoxaemia high mortality with no treatment survivors have good outcomes some might have recurrence or chronic disease
47
Sarcoidosis
systemic inflammatory condition commonly affecting lungs caused by collections of inflammatory cells forming granulomas. can affect skin, CNS, liver, heart CXR grading 1-4 - BL hilar lymphadenopathy, with infiltrate, infiltrates only, fibrosis steroids, other immunosuppressants
48
Non-ICU management of ILD
- anti-inflammatory drugs - anti-pulmonary hypertensives e.g. PDE-5 inhibitors - Antifibrotic therapies e.g. nintedanib Advanced - ILD - LTOT (symptomatic relief) - Rehabilitation - lung transplant - palliative care
49
ILD referrals to critical care
Diagnosis crucial Most commonly AIP, acute exacerbation of IPF, fulminant COP Considerations - aetiology / reversibility / response to treatment - usual therapy e.g. LTOT - complications - pulmHTN, cor pulmonale - functional status - Ix - PFTs, echo, BAL - specialist opinion Resp support - I+V usually inappropriate in IPF. NIV MDT decision Steroid - pulsed MP - rapid progressive ILD with respiratory failure cyclophosphamide
50
Sleep disordered breathing
several conditions causing hypoventilation during sleep - snoring - partial airway obstruction without sleep disturbance - OSA - intermittent complete airway obstruction - OSA syndrome - OSA with daytime symptoms - obesity hypoventilation syndrome - breathing reduced throughout sleep with or without airway obstruction. hypercapnia during day. (BMI > 30, PaCO2 > 6.5, SDB)
51
OSAS
daytime symptoms - headache, somnolescence, cognitive impairment associated hypertension, cardiovascular dysfunction contributory factors - male, smokers, obesity, reduced nasal patency overnight polysomnography - AHI - Mild < 5-15 / hr - Mod 15-30 - severe > 30 Management - conservative - lifestyle, weight loss - CPAP - mandibular re-positioning - surgery - tonsillectomy, bariatric
52
Tuberculosis
Infectious disease caused by mycobacterium tuberculosis causing respiratory and/or multisystem disease symptoms - cough - haemoptysis - fever, weight loss, night sweats
53
Critical care and TB
- respiratory failure - often associated pneumonia, COPD or malignancy. significant comorbidity e.g. HIV - Miliary TB - haematological dissemination - MODS, associated with immunosuppression CNS TB - meningitis, tuberculomas. other indications - TB related - pericardial effusion, massive haemoptysis, DIC (ciliary) - treatment related - renal / liver failure Challenges - difficult sampling infectivity - multidrug resistance
54
TB diagnosis
- sputum acid fast bacilli (or PCR) - bronchoscopy AFB (or PCR) - alternative sites - LNs, CSF, pleural effusions - overal clinical picture inc radiology Culture - 2 x sputum for MC/S - 2-4 weeks - initial ZN stainig useful - bronchoscopy high sensitivity Radiology - upper lobe nodules, cavities, lymphadenopathy
55
critical care management
- MDT (resp, micro, ID, neuro) - infection control - negative pressure, PPE - Anti-TB drugs - 6-19mo - co-infection - HIV, pneumonias - complications - steroids for meningitis, hyponatraeumia, hydrocephalus, immun reconstitution
56
ARDS definition
Acute inflammatory lung disease causing respiratory failure manifested by hypoxaemia, consolidation, reduced compliance
57
Berlin definition
1. Hypoxaemia P/F < 39.9kPA 2. Bilateral infiltrates (CT / CXR) 3. Within 1 week of trigger 4. Not explained by cariogenic pulmonary oedema Mild P/F 26.6 - 39.9 Kpa Moderate P/f 13.3 - 26.6 Kpa Severe P/f < 13.3 kPa
58
Pathophysiology of ARDS
- Epithelial and endothelial injury within alveolus - inflammation of alveolar membrane - increased permeability, protein rich pulmonary oedema - endothelial dysfunction and leakage of fluid and inflammatory cells into alveolus - inactivation of surfactant - consolidation, collapse, loss of gas exchange surface area - loss of pulmonary vascular tone and hypoxic pulmonary vasoconstriction - loss of gas exchange
59
histological phases of ARDS
1. Exudative - 1st week - protein rich fluid flooding alveoli 2. Proliferative - fibroproliferation and micro thrombi 3. Fibrotic - widespread remodelling and scarring
60
Causes of ARDS
Pulmonary - infection - bacterial, viral, fungal - aspiration - contusion - Inhalational injury - drowning Extra-pulmonary - Sepsis - Major trauma - Pancreatitis - Burns
61
ARDS treatment
underlying cause and best supportive care Mild - LPV, conservative fluid balance Moderate - prone, NMB, higher PEEP Severe - VV-ECMO if Murray score > 3 or pH < 7.2 general - nutrition, VTE prophylaxis, glycemic control
62
Steroids in ARDS
Equipoise DEXA-ARDS - mortality benefit and ventilator free days. no proning. recovery in covid-ards benefits
63
Hyperoxia
supernormal arterial partial pressure of O2 degree, duration and patient determine consequences. sometimes beneficial, sometimes harmful
64
harmful O2 therapy
patients at risk of hypercapnic respiratory failure - COPD - Bronchiectasis - Neuromuscular disease - Morbid obestiy
65
Hyperoxia recommended against in critical illness
- Acute MI - Acute stroke - Post ROSC Others - Neonatal - retinopathy, bronchopulmonary dysplasia - bleomycin - oxygen toxicity Plus - wastage - energy consumpation - fire risk - cost
66
Pathophysiology of oxygen toxicity
- ROS generated by ETC - increased imbalance between ROS and antioxidants due to hyperopia - increased exposure of tissues to toxic interactions - ROS cause harm by damaging DNA.RNA, damaging cell membrane, oxidant enzymes and impairing protein function - Exposure time and PIO2 contribute
67
Effects of O2 toxicitt
Pulmonary - epithelial damage - chest pain, reduced VC - inflammation - stages similar to ARDSm permanent fibrosis possible others - impaired HPVC - reduced CO2 elimination - altered control of breathing - absorption atelectasis CNS - nausea headache, dizziness, irritability seizures in hyperbaric conditions
68
Beneficial effects of high O2
Normobaric - CO elimination - PTX resorption - cluster headache - induction of anaesthesia Hyperbaric - decompression sickness - wound healing
69
Oxygen target trials
ICU - ROX - 90-97% vs conventional. primary and secondary outcomes no difference HOT ICU - 8 vs 12 kPA - no difference UK ROX 88-92 vs conventional - ongoing
70
HAP
pulmonary infection contracted after 48 hr of admission to hospital
71
VAP
pulmonary infection contracted after 48 hr of mechanical ventilation significance - increase LOS, ventilator days, mortality DDX - HAP/CAP - ARDS - Pulmonary oedema - contusion - PE
72
VAP diagnosis
difficult - clinical, micro, radiological features CPIS > 6 (MAX 12) - increase pulmonary secretions - fever - leucocytosis - P/F ratio - new infiltrates - +ve tracheal aspirate
73
VAP pathophysiology
Biofilm / aspiration - ETT disrupts normal host defence - secretions pool above cuff - colonised oropharyngeal - slowly migrate through folds in cuff to trachea - biofilm formation in tube - pushed in by ventilator
74
care bundle
group of evidence based interventions which together significantly improve outcomes
75
VAP prevention
care bundle - head up 30 degrees - daily sedation holds (reduce duration of intubation) - mouth care - subglottic suction - tracheal tube pressure monitoring - appropriate PPI (avoid unnecessary - bacterial overgrowth) high impact intervention - reduce VAP, MRSA, ABX other methods - hygiene during handling airway euquipment - tracheal tube design - cuff shape - SDD
76
PE Risk factors
Strong - lower limb fracture - hospitalisation for HF or AF - hip or knee replacement - major trauma - MI - previous VTE - spinal cord injury Moderate - AI disease - CCF - OCP - post-partum - cancer -thrombophilia weak - 3 d bed rest - immobility due to sitting - obestity - pregnancy
77
PE spiral of death
- increased RV afterload - RV dilaation - increased wall tension and RV O2 demand - RV ischaemia, - reduced RV contactility / output - reduced LV preload / CO / systemic BP - reduced coronary perfusion / RV O2 delivery - obstructive shock
78
PE risk strtificiation
High risk - cardiac arrest - shock - sBP < 90 and end organ hypoperfusion ( GCS, oliguria, cold skin, lactate) - persistent hypotension < 90 for 15 mins - reperfusion tx, haemodynamic support Intermediate high risk - PESI III-V / RV dysfunction (TTE/CTPA) / elevated trop - monitoring, rescue reperfusion Intermediate low - PESI III-V / RV dysfunction or troponin - hospital mx Low risk - none or above - early outpatient mx
79
PE Echo
Basal RV:LV ratio > 1 Mcconnells sign (RV free wall akinesia with sparing of the apex) flattened septum distended IVC TAPSE < 16
80
mx acute RV failure in high risk PE
- volume optimisation - cautious 500ml bolus (normal / low CVP) - NA 0.2-1mcg/kg/min - increases RV inotropy and systemic BP, restore CoPP beware excess vasoconstriction - dobutamine 2-20mcg/kg/min - RV inotropy, may worsen arterial hypotension - MCS- VA-ECMO
81
throbmolysis PE
- faster improvement in PAP, PVR vs LMWH / UFH - greatest benefit in those within 48h symptom onset - sig reduction in combined mortality and recurrence with 9.9% rate of severe bleeding, 1.7% rate of ICH - PEITHO trial intermeidiate PE - reduced haemodynamic compriomise, worse major bleeding and stroke, no reduction in 30 d mortality ABSOLUTE CI - active bleeding - CNS malignancy - haemorrhagic or ischaemic stroke last 6mo - 3/52 - major trauma, surgery relative CI - TIA - anticoagulation - advanced liver disease
82
PE scoring systems
PERC wells score - low risk - d-dimer. high risk - ctpa PESI (PE Severity index)

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