Respiratory Assessment Flashcards

Question

VC-CMV Vt Increased

Answer 1

Everything will increase with the exception of Ve which decrease and I:E Ratio which increased (specifically the E portion of this ratio will decrease)

Answer 2

* Normal VD/Vt is 0.25-0.40 but is increased to 0.40-0.60 in mechanical ventilation * Distribution of a positive pressure breath goes more to the apices and less to the bases compared to a spontaneous breath * This happens because in the apices the whole weight of the lung will be pulling down so that the alveoli is already stretched/opened * Ex. When the patient is standing up the lung will be pulling down

Answer 3

* Positive pressure ventilation will impede venous return and may result in decreased CO and therefore decrease BP * Hypotension rarely occurs in normal individuals receiving PPV due to the body’s compensatory mechanisms * Altered right and left ventilicular function * Decrease endocradial blood flood

Answer 4

The maximum pressure delivered during Does not necessarily reflect pressures in the lungs

Answer 5

PIP Increases

Answer 6

Want 3-5 cm above the carina as the tube will move as the head moves, and if we do not have a buffer zone it can extend too far

Answer 7

A measure of the distensibility of the lung Reciprocal of elastance Normal is 60-100 mL/cmH2O \< 25 - 30 cmH2O in ARDS

Answer 8

Ti dyn Decreased

Answer 9

Dirsorders in which changes in Cstat may not be reflective of changes in the CL!

Answer 10

PIP Decrease Pplat Decrease Pmean Decrease

Answer 11

1) Hemoglobin (Hb) * Oxyhemoglobin * Major carrier of O2 * 1.34 of O2 per gram of Hg (when fully saturated) 2) Dissolved in plasma * Determined by Henry’s Law * Account for a small percent of O2 transport * 0.003 mL/dL/mmHg * PO2\*0.003=ml/dl dissolved O2

Answer 12

CvO2=(Hb x 1.34 ml/g) \* SvO2 + (PvO2 x 0.003 ml/100ml/mmHg)

Answer 13

\<10%-Compatible with normal lungs 10%-19%-Seldom requires significant ventilatory support 20%-29%-Significant abnormality; requires PEEP or CPAP 30% or more-Severe disease; life-threatening; requires aggressive mechanical ventilation with PEEP

Answer 14

The anion gap is the difference between the measured cations and the measured anions Helps determine whether a decrease in HCO3- is due to disruption of normal anion balance or the presence of an abnormal acid anion (i.e. cause of a metabolic acidosis) Anion Gap = (Na+) - (Cl- + HC03-) Normal: 9 – 14 mmol/L

Answer 15

PIP Increased Pplat Increased Vt Increased Ve Increased Pmean Increased

Answer 16

Assess mask fit/leak Patient comfort Observation of skin necrosis/irritation

Answer 17

PIP Decrease Pplat Decrease

Answer 18

When it comes to ventilation the pt. has to overcome reistance (non-elastic resistance-diamater of the airways) and compliance (elastic resistance), and these are not static forces

Answer 19

* With increased airway resistance more time is needed for exhalation * Pt. still in exhalation when the ventilator gives next breath so the air that was not exhaled is now trapped * If there is not enough time before the next breath it will result in air-trapping * Air-trapping or auto-PEEP, can also be a result of obstructive lung disease (asthma, COPD) * Auto-PEEP can be measured through an expiratory pause maneuver

Answer 20

* Injury that results due to a **repeated opening and closing of the alveoli** at low lung volumes * Can also result in volutrauma because air will only want to enter the open alveoli * The collapse itself it not always damaging even though it can cause V/Q mismatching but where atelectrauma is damaging is the repeated opening and closing * Associated with **inadequate PEEP** as an appropriate PEEP will prevent de-recruitment of alveoli * Physiologic PEEP is generally 3-5 cmH2O and is caused by the backpressure in the larynx when the vocal cords are closed * Minimum PEEP is 5 cmH2O * In neonates can be associated with inadequate CPAP * A longer Ti and higher PEEP will also allows for more alveoli to open * Usually occurs in dependent area

Answer 21

The average pressure delivered over one minute, as measured by the ventilator

Answer 22

**Abbreviation:** SpO2 **Description:** Oxygen content in arterial blood **Normal**: \>90% **Measured:** Pulse Oximeter

Answer 23

* Response from hemodynamic changes * Urinary output (UO) when CO causes renal perfusion * Endocrinological Effects * Increased ADH release * Decreased ANP release * Activation of the renin-angiotensin-aldosterone system * Abnormal ABGsPaO2 results in decreased renal function and UO * Function is dramatically decreased when \< 40 mmHg * PaCO2 \> 65 mmHg decreases kidney function

Answer 24

Ventilator Settings ABG, SpO2, ETCO2, TC Ventilator Orders

Answer 25

* Size/Type * Depth * Should be the same as confirmation on CXR or adjusted to such * Position in the Mouth * Should be repositioned Q24 or more frequently * There are ETT attachment devices that will allow you to easily move the ETT without undoing everything and to help prevent pressure sores * Cuff pressure * There are automated cuff pressure monitors * Inspection and assessment of the securing method * Look for any skin necrosis/irritation

Answer 26

Any muscle not being used is subject to atrophy In patient’s with prolonged mechanical ventilation both muscle endurance and strength is compromised

Answer 27

PIP Increases Pplat Increase

Answer 28

Ti tot Decreased Te Increase I:E Decrease Pmean Decrease

Answer 29

Avoid sigh breaths with high tidal volumes and long inspiratory pauses These sigh breaths are not used very much anymore

Answer 30

**Abbreviation:** P_AO₂ **Description:** The oxygen content at the alveolus **Calculation:** PAO2= [FiO2- (Pbaro-PH2O)] - PaCO2/0.80

Answer 31

Vt Increase Minute Ventilation Increase Ti Dyn Increased

Answer 32

Where is the air in a subcutaneous emphysema is when the air collects underneath the skin

Answer 33

= presence of an abnormal acid * Lactic acidosis * Ketoacidosis * Diabetes or alcohol abuse * Toxins * Methanol * Ethylene glycol * Propylene glycol * Aspirin (acetylsalicylic acid) * Uremia (kidney failure)

Answer 34

Want to try and keep FiO2 lower than 60% as above which this risk for O2 toxicity will greatly increase So just because a blood gas looks good does not mean there is no work to do

Answer 35

PIP Increased Ti_dynDecreased Ti_totDecreased Te Increase I:E Decreased

Answer 36

Ve Decreased Te Increases I:E Decrease Pmean Decrease

Answer 37

The volume of gas that is inhaled but does not take part in gas exchange VDphys = VDanat + VDalv As deadspace increases the work of breathing to maintain alveolar ventilation is increased For a given PaCO2, as the VD is increased the ṾE must increase as well, in order to maintain PaCO2 At ṾE \> 10 LPM there is increased probability of respiratory failure developing 2° to muscle fatigue

Answer 38

Use the appropriate PEEP By minimizing the risk of these VILI will minimize the release of inflammatory mediators and the resultant biotrauma

Answer 39

A reliable index of poor oxygenation is if FIO2 \> 0.50 and PaO2 \< 100 mm Hg and this means that the patient is getting a lot of oxygen but for some reason it is not getting into their blood

Answer 40

Perfusion will go to gravity dependent areas and ventilation will go to gravity independent areas The gravity dependent areas will be located on the posterior side when the patient is lying on their back

Answer 41

OI = (FiO2 \* MAP \*100) / PaO2 A calculation that takes into account the mean airway pressure (MAP) If you are using FiO2 as a decimal then times by 100 if you are using it was a whole number then you do not need to multiple by 100 Positively correlated with mortality risk You want a low OI (the lower the better) with \<5 being normal When you are in the 20 you need to begin to look at things such as ECMO because you lungs can no longer properly oxygenate the blood

Answer 42

* Always looking to see if the follwing are changed * Compliance * Resistance * Auto-PEEP * Done through an assessment of the: * Ventilating pressures/volumes * Waveforms

Answer 43

Critical Numbers \> 350 mmHg when a person is on oxygen

Answer 44

The lung will release inflammatory mediators that will attack lung tissue, as a result of volutrauma and/or atelectrauma This results in lung injury that resembles ARDS **The inflammatory mediators can also enter the systemic circulation and result in injury in other organs.** Meaning that poorly manage ventilation can lead to serious organ dysfunction in other areas of the body. All of the blood in the body will pass through the lungs which is why the inflammatory mediators can travel to the other parts of the body. This also means that severe injury/infection from other parts of the body can result in ARDS from the inflammatory mediators released from other parts of the body

Answer 45

**Abbreviation:** CaO2 **Description:** Total amount of oxygen contained in arterial blood (going to the body) **Calculation:** CaO2=(Hb x 1.34 ml/g) \* SaO2 + (PaO2 x 0.003 ml/100ml/mmHg) **Normal**: 16-22 mL/dL (vol %)

Answer 46

Over time the alveolar units will collapse when awake we will sigh or yawn to help prevent this collapse, when a patient is sedated and paralyzed they will be unable to yawn or sigh meaning we will have to do it for them Use high pressure at 30-40 and hold for 30-40 seconds

Answer 47

Minute Ventilation Decreases Te Increases I:E Decrease

Answer 48

* **Increased Affinity for Oxygen** * Decreased temp * Decreased 2-3 DPG * Decreased [H++] * Increased pH * CO * Because once it has bound to CO it will want to bound with more O2 but it is still easier to bond with CO because there is a stronger affinity

Answer 49

* Positive pressure ventilation (and use of PEEP) will increases intrapleural pressure, because how much of the pressure we are pushing in it transmitted to pleural membrane, as well as and intrathoracic pressures * The extent of the transmission is dependent on: * **Amount of PEEP and PPV** * This become more and more of an issue and PEEP and PPV becomes higher * **Lung compliance** * Low C (e.g. ARDS): Pressure transmission significantly reduced * Low compliance means that there is a higher elastic recoil (stiff lungs) and the lungs pulling inwards working against our positive pressure ventilation trying to push outwards * High C (e.g. COPD): Pressure transmission is highest * Can be regionally affected due to disease process-eg. pneumonia, atelectasis * **Thoracic compliance** * Thoracic compliance is the resistance of the chest to expansion * Hemodynamic compromise is most likely to occur when thoracic compliance is low (e.g. Abdominal distension, thoracic deformities-Kyphoscoliosis)

Answer 50

PIP Decrease Ti_dynIncreases Ti_totIncreases Te Increases I:E Increases

Answer 51

Reflects the pressure in lung at end inspiration Requires an inspiratory pause maneuver to measure

Answer 52

Ti dyn Increase

Answer 53

* Quantifies the level of lung injury in ALI/ARDSe * A composite score that takes into account the following four factors: * CXR findings * PaO2/FiO2 * PEEP setting * Lung compliance * No lung injury would be a score of 0 * Not commonly used clinically but can be used more in research * The specific scoring will not be testable (but what is above will be)

Answer 54

Normal P/F ratio is 400 to 500

Answer 55

PIP Increase Pplat Increase Pmean Increases

Answer 56

Minute Ventilation Increases Te Decreases I:E Increases

Answer 57

The effect of PPV on the respiratory system

Answer 58

When a person deteriorates rapidly well on a mechanical vent we can use the acronym of DOPE, which stands for * **D**isplacement of ETT * **O**bstruction of ETT * At this point try to suction the placement, and if the suction gets stuck it means that there is an obstruction * **P**neumothorax * Preventing air from entering the lungs. * When there is a rapid deterioration you will not have enough time to get an x-ray so it is at this time you will want to use your IPPA to determine the likelihood of a pneumothorax * **E**quipment Malfunction

Answer 59

Ti dyn Decreased

Answer 60

Related to atelectrauma This is the strain exerted on the alveolar wall between the expanded lung unit and de-recruited lung unit Occurs in interstitial space between the open and the closed alveoli Capillary injury and release of inflammatory mediators results This can be a common problem in neonates as the alveoli can collapse easily, and is why we tend to use CPAP with neonates to keep the lung open

Answer 61

Chest Tubes Humidity Bronchopulmonary Hyigene- VAP Protocol, CPT, bronchoscopy Ventilator Strategies-Lung proctective, LVRM, prone proning Readiness for weaning

Answer 62

Vt Decrease Minute Ventilation Decrease Ti Dyn Decrease

Answer 63

* Use appropriate volumes and make sure not to over ventilate * 6-8 mL/kg in normal lungs and 4-6 mL/kg in ARDS * Maintain alveolar pressure \<30 cmH2O * Consider permissive hypercapniaWe don’t always need to ventilate to normal blood gases as sometimes a high CO2 can be used as a protective strategy * People will not die because there high CO2 is high they will die because their O2 is low, meaning we should sacrifice ventilation before we sacrifice oxygenation * It is more important to monitor pH than CO2, but we can get orders to just keep pH higher than 7.25

Answer 64

PIP Increased Pplat Increased Pmean Decreased

Answer 65

Pulse oximeters Co-Oximeters Capnographers Transcutaneous

Answer 66

Inhaled Medications Systemic Respirtory Medications Specialty Gases

Answer 67

Because this is a complexed task it overlap different assessment categories * **Basic Assessment** * Basic respiratory parameters * Because ventilator is ventilating the lung, part of chest assessment is checking the ventilator * **Non-Patient Assessment** * Circuits * Device check * Preventative Maintenance * **Monitoring and Diagnostics** * Continuous display of waveforms/parameters * Lung mechanics and WOB * **Therapeutic Intervention** * Supports respiratory system

Answer 68

* May decrease due to an improved ABGs * Giving oxygen will dilate vasculature * May be increased due to compression of alveolar capillaries and over distension of alveoli * Can also result in a decreased pulmonary perfusion * This means that both hypoxemia and high pressure from PPV can cause higher PVR, so in order to reverse it we need to known the mechanism that it causing it * This is difficult to determine at the bedside, but new technology is coming out in order to make this easier

Answer 69

Pneumothorax is when air leaks into the space between the lung and chest wall

Answer 70

* **Spontaneous Breath** * Diagram contracts to create a negative pressure and the negative pressure will also stretch the vena cava and pulls the venues blood from extremities against gravity, ultimately improving venous return to the heart. * **Positive Pressure Breath** * The opposite is occurring because we are pushing pressure in and making atrium smaller and restricting venous return. * We are also assuming the right ventricular output will decrease as well. * What the picture below is showing will not happen for all pt. as some pt. may be more susceptible than others

Answer 71

**Increased Lung Compliance** * Improvement in any of the above, pulmonary emphysema **Increased Thoracic Compliance** * Improvement in any of the above, flail chest, position change—sitting patient up

Answer 72

* Ventilator Circuit Changed * Scheduled Change * Soiled * Leak Test Failure * Humidification Delivery Changes * Ventilator Change * Routine Change for PM * Changed- Mechanical Failure * Not Changed-Patient Unstable * Device Checks Performed * Automated * Pressure Test

Answer 73

Vt Increase Ve Increase Ti Dyn Increased

Answer 74

* **Reduced Affinity (tendency to bind) for Oxygen** * Increased temp * Increased 2-3 DPG * Increased [H++] * Decreased pH * A decrease in the amount of O2 associated with hemoglobin in response to a decreased pH is known as the Bohr Effect

Answer 75

Airway Safety Equitment Suction Equitment Humidification Equitment Vent/Circuit Maintenance

Answer 76

As each of the four binding sites on a Hgb molecule binds to an O2 molecule its attraction to other O2 molecules will increase. This is why there is the steep curve at the beginning. Once all the binding sites have been filled up (hemoglobin is saturated) the curve will plateau. This point will be at a saturation of 90% and a PaO2 of ~60 mmHg. **Above this point big changes in oxygenation will result in small chnges in PaO2.** At sat of 50% there is a PO2 of 27 Review curve shifts Right sided shift- increased temp, increased CO2, decreased pH (increased hydrogen ion concentration), increased 2,3 DPG. So increased everything except pH which decreases

Answer 77

The continued stress of mechanical ventilation can result in: * Insomnia/Sleep Deprivation * Anxiety/Frustration * Withdrawal Syndromes * Depression * Feelings of helplessness, loss of control * Can become psychologically dependent upon the machine * Fear

Answer 78

Everything will decrease with the exception of Ve which increase and I:E Ratio which decreased (specifically the E portion of this ratio will increase)

Answer 79

Ti_total Decrease Te Increase I:E Decrease Pmean Decrease

Answer 80

**Time Constant=Resistance x Compliance** ## Footnote A single time constant is the time it will take to inflate 63% of alveolar units Five time constants is when all alveolar units are expanded RR can be broken down to inspiratory time and by default exhalation time If exhalation time is too short then we can have air trapping Strategies to increase Te= Decrease Ti

Answer 81

**Oxygen is not being effectively transferred from alveoli to the blood** ## Footnote V/Q Mismatch Right to Left Shunt Alveolar hypoventilation Diffusion Defect

Answer 82

Positive pressure dilates the conducting airway

Answer 83

Related to a **high transpulmonary pressure** that results in a **overdistension of the alveoli,** as air will always follow the path of least resistance and will then over distend the non diseased alveoli sac If the sac becomes rupture and not just over distended then it is considered to be barotrauma not volutrauma The stretch in the alveoli will cause a “leaky” AC membrane (gaps between the alveoli cells) which cause **edema formation** in the area which results in the release of inflammation mediators and a presentation that is similar to ARDS (massive inflammation in the lungs) and the edema can leak secondary into the alveoli

Answer 84

\< 300 = in acute lung injury (ALI) also known as early ARDS \< 200 = in acute respiratory distress syndrome (ARDS)

Answer 85

Normal PaO2= 100-80 mmHg Mild PaO2= 60-79 mmHg Moderate PaO2= 40-59 mmHg Severe PaO2= Less than 40 mmHg

Answer 86

The most acute, immediate, and severe form of VILI Risk increases with the level of alveolar pressure (Pplateau) and the extent of lung injury or previous lung disease Will occur from trying to push air in too fast Results in air outside of the alveoli (extra-alveolar air) due to the positive pressure rupturing the A/C membrane Can result in air-leak disease (diseases when air collects outside of the alveoli)-Subcutaneous emphysema, pneumothorax, pneumomediastinum

Answer 87

Ti tot Increased Te Decrease I:E Increased Pmean Increased

Answer 88

Ti dyn Increase

Answer 89

PIP Increased Pplat Increased Pmean Increased

Answer 90

The ratio of partial pressure arterial oxygen and the fraction of inspired oxygen Will help to determine the degree of any problems with how the lungs transfer oxygen to the blood

Answer 91

Use PEEP cautiously in patients predisposed to alveolar rupture Monitor for auto-PEEP

Answer 92

Compliance (imaginary line between start of inspiration and expiration) **Increased Compliance** * Left Shift of the curve * Ex. Advanced Emphysema **Decreased Compliance** * Decreased volume for pressure change * Will be a right shift of the curve * Ex. Pulmonary Fibrosis

Answer 93

Pneumomediastinum is when air collect into the mediastinum

Answer 94

Vol% is equal to ml O2/ 100 ml of blood The amount of O2 in mls that is in 100 ml of blood

Answer 95

The ratio of physiological deadspace to tidal volume Normal VD/VT = 0.2-0.4 ICU common to be \>0.70 \>0.60, patient is unlikely to sustain spontaneous ventilation VD/ VT = (PaCO2 - PECO2) / PaCO2 When CO2 goes up, pH will go down For end tidal CO2 (PaCO2) which DOES NOT EQUAL PeCO2 which is the total amoutn of CO2 removed in one minute PeCO2 will be given whenever we have to calculate deadspace

Answer 96

Impaired liver function 2° to decreased CO PEEP has more impact on hepatic blood flow than PPV (PIP)does

Answer 97

Interstitial emphysema is when air collects in the lung supportive tissue known as pulmonary interstitium

Answer 98

PIP Decrease Pplat Decrease Vt Decrease Ve Decrease Pmean Decrease

Answer 99

* Tactile Fremitus and Crackles on Auscultation * Complete suctioning * High WOB * Adjust ventilator settings

Answer 100

When a wedge pressure is higher the 18 non cardiogenic pulmonary edema is likely to occur

Answer 101

In a healthy pt. 21% O2 (room air) will produce a gradient of 5-15 mmHg (10-20 in elderly) Normal A-a gradient=Age divided by 4 plus 4 Ex. A 40 year year old should have an A-a gradient of less than 14 100% O2 gradient is 100-150 mmHg The normal range will change depends on how much oxygen the patient is on. This means that the value of using A-a calculation for determining oxygenation will decrease as the patient is on an increased FiO2 (most useful when on room air)

Answer 102

* Reason for Changing Open Suction Catheter * Soiled * Faulty Valve * Sticky Catheter * Cutting of Sleeve * Faulty Instill Pot * Suction Equipment Changed * Yankuer * Yankuer Holder * Closed Suction Catheter * Suction Tubing * Canister Liner

Answer 103

**Extrinsic PEEP (= PEEPext = PEEPset)** * Directly set on the vent **AutoPEEP or Intrinsic PEEP (= PEEPauto = PEEPint)** * Cannot be determined by simple observation of the ventilatory pressures; can be determined to be present through inspection of the expiratory flow waveform * Requires an *expiratory pause maneuver* to measure (i.e. quantify) **Total PEEP (PEEPtot)** * Reflects the total pressure in lung at end expiration PEEP_tot= PEEPext + PEEPauto

Answer 104

upper inflection point = maximum setting for peak airway pressure Has been proposed as a way to detect overdistention in the lungs, but this approach appears to be too simplistic as other parts of the lungs will already be over distended by the prior to reaching this point ‘Beak’ or ‘duckbill’=increase in airway pressure without any appreciable increase in volume

Answer 105

Qs/Qt= (CcO2-CaO2)/(CCo2-CvO2) Where: Qs = Pulmonary Physiologic Shunt (mL/min) Qt = Cardiac Output (mL/min) CCO2 = End-pulmonary-capillary Oxygen Content CaO2 = Arterial oxygen content CVO2 = Mixed Venous Oxygen Content

Answer 106

This is a measure of the difference between the alveolar concentration of oxygen and the arterial concentration of oxygen Will be used to help diagnose the source of hypoxemia and whether it is an intrapulmonary or extrapulmonary problem Will help to assess the intgreity of the alveolar capillary unit

Answer 107

Ventilator-Induced Injury can be divided into the following categories * Barotrauma * Volutrauma * Atelectrauma * Biotrauma * Oxygen Toxicity

Answer 108

The time required to inflate (or deflate) a lung region Complete filling requires 5 time constants 1 TC = 63% 2 TC = 86% 3 TC = 95% In a pressure-controlled breath can be determined by the time it takes for equilibration to occur Time Constant= Resiatance x Compliance

Answer 109

Most people will not be affected by this as the body will be able to compensate it is the septic, spinal injury patient that will be very problematic as we exceed the body’s capacity to compensate Hemodynamically unstable patients (low BP etc.) Patients with high lung compliance or low thoracic compliance (as transmission of the positive pressure to the thoracic space is greatest in these patients) Worst case is a COPD pt. (higher lung compliance) with low thoracic compliance

Answer 110

Ve Increase Te Decrease I:E Increase Pmean Increase

Answer 111

Can be measured as a dynamic or static technique Dynamic: Requires a square inspiratory wave form to interpret – constant flow and no inspiratory pause Static: Requires paralysis and measures of pressure with small incremental in volume

Answer 112

The shunt equation looks at the extent to which venous blood bypasses the capillaries (oxygenation) of the lungs Increased if pulmonary venous admixture occurs (mixed venous blood exits A/C membrane unchanged)

Answer 113

**Abbreviation:** P(A-a)O2 **Description:** A measure of the difference between the alveolar concentration of oxygen and the arterial concentration of oxygen **Normal:** Age divided by 4 plus 4 **Calculation**: P_AO₂- P_aO₂

Answer 114

When assessing bronchopulmonary hygiene we need to look for * Color * Consistency * Tolerance by the patient * Cough * Spontaneous * With Stimulation * Not Present * Assess for Trends * Total passes of suctioning needed

Answer 115

**Dynamic Compliance:** Done during dynamic conditions (i.e. airflow), thus is impacted by Raw! Not too useful clinically. Cdyn = V_Teff/ (PIP - PEEP_tot) **Static Compliance:** Done during static conditions (i.e. no airflow), thus is a reflection of compliance only! Cstat = VTeff/ (Pplat - PEEPtot)

Answer 116

Gas Exchange

Answer 117

Oral and trach care can and often is done at the same time

Answer 118

* Bedside Respiratory Safety Equipment * Manual Resuscitator * Masks * Airway * Airway * PEEP Valve * Trach Bag * Oxygen Tank * Wire Cutters * Intubation Supplies * Cricothyrotomy Tray

Answer 119

PIP Increased Pplat Increased Vt Increased Ve Increased Pmean Increased

Answer 120

A graphical representation of the relationship between pressure and volume during inspiration and expiration Spontaneous breaths go clockwise and positive pressure go counter clockwise In pressure control or PS the loop is almost square because of pressure limiting during inspiration Bottom of loop is either 0 or PEEP level Top of loop = PIP

Answer 121

Small ETT, plug in ETT, biting on ETT Increased bronchospasm, mucosal edema, secretions, and/or airway obstruction Increased inspiratory gas flow rate

Answer 122

Ti_total Increase Te Decrease I:E Increase Pmean Increases

Answer 123

PIP Decrease Pplat Decrease Vt Decrease Ve Decrease Pmean Decrease

Answer 124

V_E Will typically be monitored by the ventilator V_E=RR x Vt

Answer 125

Loop won’t meet the bottom

Answer 126

The frictional resistance to gas flow Varies; is dependant on the driving pressure Changes throughout inspiration and expiration thus, most commonly, and more simply, calculated during constant flow (ie. VCV) Normally 1 to 2 cmH2O/L/sec Intubated, probably 5 to 10 cmH2O/L/sec or more Raw = (PIP – Pplat) / flow Transwairway Pressure is (Pm – Palv)

Answer 127

**Decreased Lung Compliance** * Atelectasis, pneumonia, pulmonary edema, ALI/ARDS, pneumothorax, fibrosis, bronchial intubation **Decreased Thoracic Compliance** * Obesity, ascites, chest wall deformity

Answer 128

Hypoxemia is defined as a condition where arterial oxygen tension (Pao2) is below normal (normal Pao2 = 80–100mmHg). Hypoxia is defined as the failure of oxygenation at the tissue level. Generally, the presence of hypoxemia suggests hypoxia. However, hypoxia may not be present in patients with hypoxemia if the patient compensates for a low Pao2 by increasing oxygen delivery. This is typically achieved by increasing cardiac output or decreasing tissue oxygen consumption. Conversely, patients who are not hypoxemic may be hypoxic if oxygen delivery to tissues is impaired or if tissues are unable to use oxygen effectively. Nevertheless, hypoxemia is by far the most common cause of tissue hypoxia.

Answer 129

PIP Decrease Pplat Decrease Pmean Decrease

Answer 130

Bronchodilator administration Suction and airway care Use of lower inspiratory gas flow rate

Answer 131

* PPV takes over all or part of the WOB * Decreased O2 consumption and CO2 production by respiratory muscles but… * Hypermetabolism is associated with major illnesses/surgical procedures * Proper nutritional intake for patient’s size and illness; malnutrition a major concern * But we now have a tube down their throat blocking their ability to swallow making it more difficult to provide nutrition * Morphine will also slow down time to move food throughout the body making even more of a problem because the body needs more nutrients

Answer 132

This is the minimum oxygen concentration that is needed to provide enough oxygen to prevent ischemia in the tissues Once the O2 sat falls below 90%, the PaO2 drops quickly into the dangerously hypoxic range as fewer and fewer oxygen molecules are bound to Hgb. We want to try to keep O2 saturation above 90%.

Answer 133

Line drawn down middle of loop On inspiration (area to right side of line) On expiration (area to left side of line)

Answer 134

1) Increase PEEP 2) Increase FiO2 3) Increase Ti_total * Increase mean airway pressure by increasing the I:E ratio * 1:1 is a higher I:E ration compared to 1:4 (think of it as 1/1 and ¼ and then then answer for 1:1 is 1 and for 1:4 is 0.25)

Answer 135

PIP Decreases Pplat Decreases Tidyn Increases Pmean Decreases

Answer 136

PIP Increases Pplat Increases Tidyn Decreases Pmean Increases

Answer 137

Decreased Tidyn

Answer 138

* Mechanical * Elastic and non-elastic work * Metabolic * Oxygen consumption * Relationship of work, rate and depth of breathing to muscle fatigue * Readiness to Wean from ventilator

Answer 139

Associated with the amount of negtaive pleural pressure that is generated during a ventilatory effort 2/3 Due to Elastic Resistance 1/3 due to Non-Elastic Resistance

Answer 140

Normally passive High Raw may need more expiratory muscle wokr

Answer 141

Uses an esophageal pressure monitor to reflect intrapelural pressure changes The pressure time product is calculated from the area underneath the generated curve PTP is a simpler measure than WOB and will parelle the change in effort and VO2 cost of breathing

Answer 142

Will be narrow and long in restrictive diseases Will be wide in obstructive lung diseases

Answer 143

We will try to breath while using a minimal amount of work A normal healthy young adult will have a Vt of 500-600ml

Answer 144

Fast breathing will produce high flow rates which increases Raw Large tidal volumes will require a strech in the lung and increase elastic work Both of the above will increase WOB but the body will adapt a RR and Vt in mimize WOB

Answer 145

The amount of O2 that is consumed by the ventilatory muscles (VO2R) will give and estimate of respiratory effort Noral is 2-5% of total VO2 Upon dsypnea this can increase to 30% and even up to 10 times normal amount in COPD. Will also increase with obseity, fibrosis and congestive failure Measures by (not commonly used) **VO2R=VO2 in active breathing-VO2 apnea**

Answer 146

The compatability between the patient bretahing effort and the ventilator Important to consider: Mode, Phase Variables

Answer 147

Can be seen on patient assessment as well on the monitor it will look like random swiggly lines in between breath

Answer 148

In volume control if the limit variable is not set properly we may not be meeting inspiratory demands of the patient and instead of a straight steady increase on the pressure waveform there will and a depressed upwards curve In pressure control the patient will be able to compenstate for the limit varaible through varying flow and volumes

Answer 149

Ideally we want to see pressure equilibrium at the end of inspiration in pressure limited mechanical breaths

Answer 150

Many vents will allow for the adjustment of the flow cycle level Tailor to pt, and situation

Answer 151

Non-invasive measurement of arterial oxygen saturation An oximeter is an instrument that measures the amount of light absorded/ transmited through the blood Based on photoplethysmography and spectrophotometry

Answer 152

Uses light absorption to detect tiny volume changes that occur in the tissues due to blood pulsing in the vascular beds The amount of light that is absorbed is proportional to the amount of blood flow Maximum absorption during systols and minimum during diastole So this detects perfusion/ pulsatile blood flow

Answer 153

Is the science taht uses light wavelengths to measure light absorption through a substance in this case blood There are two wavelengths that are used in pulse oximetry: Red light (660nm) and infrade light (940 nm)

Answer 154

Basis of spectrophotometry The amount of light a substance will absorb depends on the amount of substance and on the concentration of the substances in the sample. As the concentration of a substance increase so will the light absorded

Answer 155

Designed to measure either transmitted or reflected light Uses LEDs to send the light wavelengths Has a photodetector to measure the transmitted (or reflected) light

Answer 156

Finger, Toe Ear Bridge of Nose Forehead Infant: Across the foot or hand

Answer 157

The displayed value: SpO2 This is called a **functional saturation** (not to be confused with fractional saturation) **Functional saturation** is the ratio of HbO2 to the total Hb available for binding with O2 Functional saturation does not take into account the dysfunctional hemoglobin's, like HbCO or metHb

Answer 158

+/- 3-5% You can have false high readings when SpO2 is \<80% The lower the sat the more likely it will read to high which is why it is important to compare against blood gas

Answer 159

Motion Low perfusion External lights False nails/ Nail polish Wrong type of sensor Incorrect placement (too tight or loose) Dysfunctional Hb, anemia Vascular dyes

Answer 160

•Motion interference Low perfusion Dysfunctional Hb present Anemia Venous pulsation Ambient light interference Electrical interference Optical cross talk Optical shunt

Answer 161

Uses different wavelengths to calculate and display SpO2 SpMet- Altered shape of hemoglobin making it difficult to bind to an incorrect number of Fe and can be caused by tropical anaesthetics (Lidocaine) SpCO SpHb SpOC

Answer 162

Combines fibre-optics with an indwelling catheter to allow for **continuous** monitoring of SvO2 (via PAC) SjvO2 (via catheterization of the jugular vein) Based on reflectance spectrophotometry

Answer 163

=Hemoximetry Based on the principal that different forms of Hb absords light differently at different wavelengths Uses four (or more) wavelengths to measure Hb, HbO2, HbCO, and MetHb

Answer 164

The saturation we see from a co-oximeter is the **fraction saturation** **Fractional Saturation:** Ratio of Hb bound with O2 compared to the total amount of Hb present Total Hb includes HbO2, Hb, and dsyfunction Hb

Answer 165

**Capometry**: Measurement of CO2 in exhaled gases; provides digital display of EtCO2 value (i.e. a number) **Capnography** is a graphic display of CO2 level as they change dueing breathing

Answer 166

Infraded absorption spectroscopy is the most common method Can be main stream (directly in line with flow) which is more accurate. Or side stream which is a line coming off the flow tubing and can easily get damaged or filled with secretions or fluid

Answer 167

End tidal CO2 is closely related to PaCO2 A normal PetCO2 averages 3-5 mmHg less than PaCO2 A PaCO2 greater than ETCO2 is indicative of a V/Q mismatch Can help in confirmation of ETT placement and the effectiveness of CPR A sudden increase in the P(a-et)CO2 can indicate a pulmonary embolus.

Answer 168

**Culture:** Determines the presence and identification of bacteria or fungi in the sputum **Sensitivity:** Determines which antibotics the culture is sensitive too and will be the most effective

Answer 169

A bronchoscope is advanced into a lung segment and wedged in the bonchus Sterile saline is flushed into the segment and then suctioned back up thru the bronchoscope The sample is collected in a sterile container and is analyzed via a culture and sputum Can also help determine if an inflammatory process is under way due to the presence of neutrophils, and can somtimes detect food particles is aspiration has occured

Answer 170

Takes on multiple cross sectional images of the chest (or other) about 1 cm apart Helical CT take these images very quickly and can allow for an *angiography* to occur when a contrast dye is administered intravascularly

Answer 171

The perfusion scan is obtained by injecting radiolabeled albulmin intravanesously The ventilation scan is obtained by having the patient breathe in a radiolabled gas A gamma camera collects the images

Answer 172

Provide imagining (a "map") of the distribution of ventilation, allowing localization and quantification of areas of injury "Quiet" regions are those without ventilation and will not be seen in the scan Is dynamic monitoring and can provoke continuous monitoring or a spot check Can help to evaulet optimal PEEP levels and the effect of recruitment maneuver, and other aspects of ventilation

Answer 173

1) Electrical Impedance Tomography 2) Acoustic Respiratory Monitoring (ARM)

Answer 174

Uses 16-32 electrodes placed around the chest Impedance between the electrodes is measured A video reconstruction of ventilation will be created

Answer 175

Uses a series of stethscopes placed around the chest Ventilation map is created from the sounds

Answer 176

Chest tubes are used to help manage pleural diseases There are a range of sizes Will typically be connected to either a Heimlich valve or thoracic drainage unit CXRs are helpful in assessing location and depth for insertion, as well as resolution of the original problem Percussion and auscultation can be helpful in assessing the effectiveness of this therapy An assessment of the dressing and/or site can reveal onset of infection and/or air leaks

Answer 177

Most common method for our adult patients Achieved through the use of an HME or HMEF

Answer 178

Heated humidifier and heated wires in the circuit Indications * Bloody secretions * Thick, tenacious sputum * Hypothermia (core temp \<32 °C) * Burn patients * Patients where HME contraindicated * Neonates; small peds * High MV or large leaks leakscausing Vte\< 70% of inhaled

Answer 179

Ventilator-associated pneumonias are caused by the micro-aspiration of the micro-organisms in oral and gastric secretions 30-Cuff Pressureto keep secretions out (25-30) 30-HOB at 30 degree angle 30-Suction on EVAC tube

Answer 180

Perform gentle suctioning Minimize circuit changes Use MDI’s (not SVNs) for med delivery to intubated patients Daily SATs and SBTs (to reduce duration of intubation) Use NIV when possible Perform oral hygiene every 4 hours at minimum Oral, not nasal, gastric tubes Measuring gastric residual volumes Many institutions have a “ventilator bundle” where two or more strategies to reduce nosocomial pneumonia and VAP are combined.

Answer 181

The low compliance necessitates smaller VTto keep plateau pressures \< 30 cmH2O VT in the 4-6 mL/kg range PEEP is important to maintain recruitment High levels of PEEP may be indicated Can use the static (or low-flow) V-P curve to help determine ABG targets * The low VT often results in a permissive hypercapniastrategy * PaCO2 allowed to climb as long as pH \> 7.25 * Minimal FiO2 to keep SpO2 \> 90% (typically)

Answer 182

* (Typical) ABG targets: * Low-normal PaCO2 (35-40 mmHg) * High-normal pH (7.40-7.45) * Slightly vasoconstricts vessels to the brain resulting in decreased ICP * PaO2 80-120 mmHg * Ventilator settings: * Typically normal lungs so follow settings for normal lungs

Answer 183

**COPD vs Asthma** * Problems with airway resistance, but by different mechanisms * Asthma: bronchoconstriction; narrowed airway lumen * Maximize time * Push breath in fast and give it time to exhale (increase flow or Ti) * COPD: the high lung compliance results in “floppy” airways and airway collapse on forced exhalation * Inhalation is easy and exhalation is difficult * Both have high time constants resulting in prolonged expiration time required; auto PEEP is common * Ventilator settings: * Main goal is to maximize expiratory time in order to decrease the auto PEEP

Answer 184

Original reason for mechanical ventilation is resolved Patient has stable vital signs/hemodynamics Patient should be able to manage WOB on their own This is where weaning parameters help

Answer 185

Able to maintain their airway Good LOC or has TT in place Cuff leak is present Is able to protect their a/w Presence of cough and gag reflexes Is able to manage their secretions Look at sxn history, effectiveness of cough

Answer 186

Spontaneous VT4-6 mL/kg \*RR \< 35 bpm \*VC \> 10 mL/kg \*NIP (MIP) \> 20 cmH2O f/VT\< 105 (also known as the RSBI or Tobin score) MV \< 12-15 LPM So this is what we used to assess know there are also other things we look for as studies have shown that these weaning parameters are not a good indice of how well they will wean

Answer 187

Using weaning parameters alone are not good predictors of succesful weaning and the **best parameter in the SBT** Studies have shown that 75% of patients need NO weaning Weaning should take on the form of screening for readiness for discontinuation from mechanical ventilation rather than an approach that steadily reduces ventilatory support Still need to balance FVS vs. PVS until SBT is passed

Answer 188

Ideall done once daily in combination with a SAT Patient will be placed on a mode that provides minimal assisstance (PSV, CPAP, T-piece) Can assess the patient’s spontaneous breathing from 30 min up to 120 min The longer they have been ventilated, the longer the SBT Tobin Score and WOB assessed throughout

Answer 189

**Respiratory Factors**-Increased ventilatorydemand, muscle atrophy, abnormal lung mechanics (R or C) **Cardiovascular Factors-**MI, arrhythmias, hemodynamic instability **Neurological Factors**-Decreased drive to breathe, impaired neurotransmission **Psychological Factors-**Fear of removal of life support, anxiety, stress, depression, sleep deprivation

Answer 190

Most common; typically used to deliver bronchodilators and ICS Requires a special actuator to adapt the MDI to the ventilator circuit (ideally has a chamber to increase aerosol delivery to lung) Requires timing of the actuation with inspiration Often the dose is adjusted due to “loss” to the circuit

Answer 191

Nebulization during inspiration only results in greater delivery of the drug If the nebulizer is external to the vent it can add to the delivered tidal volume and interfere with triggering These disadvantages and the increased risk of contamination mean we typically use MDIs Inhaled antibiotics (e.g. Gentamicin, vancomycin) or mucolytics(i.e. drugs not available in MDI) may be given via nebulized treatment

Answer 192

A colourless, odorless gas It is produced endogenously in vascular endothelial cells and is a potent vasodilator Because it is inhaled it is selective to the pulmonary system and thus is a potent pulmonary vasodilator Administered via the INOvent T’s in NO, servo-controls and analyzes levels Common Uses-ARDS, Pulmonary hypertension, Neonates (PPHN, congenital heart defects)

Answer 193

The pulmonary vasodilation results in: Decreased PVR Decreased pulmonary artery pressures Decreased intrapulmonary shunting Better V/Q matching as NO increases blood flow only to ventilatedalveoli by relaxing the smooth muscles of the capillaries supplying these alveoli Improved oxygenation Effects are limited to the pulmonary circulation because after diffusing into the capillaries NO immediately binds to hemoglobin

Respiratory Assessment Flashcards

(217 cards)