Respiratory Distress & Oxygen Flashcards
(40 cards)
1
Q
Indications of respiratory distress
A
- Increased respiratory rate
- Nasal flaring
- Intercostal & sternal retractions
- Visible expression of distress
- Increased use of neck accessory muscles
- Paradoxical breathing
2
Q
Causes of tachypnea & bradypnea
A
- Tachypnea: exercise, atelectasis, fever, hypoxemia, anxiety, pain
- Bradypnea: head injuries, sedation, drug overdose
3
Q
Describe low flow O2
A
- Variable O2 concentration
- Does not meet the entire inspiratory flow demands resulting in the entrainment of ambient air
- FiO2 can vary depending on respiratory drive & breathing pattern
- Less than 4 LPM generally do not need humidification
4
Q
Describe high flow O2
A
- Fixed O2 concentration
- Minimizes variability in FiO2 & meets the inspiratory flow demands of the patient
5
Q
Types of oxygen delivery devices
A
- Simple mask
- Aerosol mask
- Venturi mask
- Partial non-rebreather
- Non-rebreather mask
6
Q
Benefits and barriers to a nasal cannula
A
- Benefits: raises PaO2 to decrease hypoxia, allows for eating/drinking/speaking, convent use
- Barriers: dries nasal passages, narrow range of adjustment if pt becomes increasingly hypoxic
7
Q
Describe the use of a reservoir/Oximyzer
A
- Stores O2 during exhalation & allows for greater O2 to be inhaled with a lower flow rate
- Allows for portability & conservation of O2 supply when ambulatory/exercising
- May by in the facial area
8
Q
Benefits of face masks
A
- Inexpensive
- Allows for higher O2 concentration, 5-8 LPM and 40% to 60% respectively
- Raises PaO2 to decrease hypoxia
- Can be used for mouth breathers or for those with nasopharynx obstructions (polyps, etc.)
- Usually used for short duration such as post-operatively previously (now being used more frequently with therapy)
9
Q
Barriers for face masks
A
- Does not allow patient to eat, drink or easily communicate
- Ill-fitting, uncomfortable
- Can block vomitus
10
Q
Describe the differences b/w a nasal cannula and a “cool” high flow nasal cannula (HFNC)
A
- NC: flow rates b/w 1-6 L/min for adults
- HFNC: dosage 6-15 LPM (liters per min), alternative to face O2, MUST be humidified via a rigid bubbler/humidification canister
11
Q
Describe a venturi mask
A
- Can be converted to fit a trash collar to also allow those pts with a trash to mobilize easier
- O2 delivered through tubing into mask (not closed system), mixes with room air
- Max FiO2 that can be delivered is 55-60% FiO2
12
Q
Describe a non-rebreather mask (NRM)
A
- Used when mobilizing pts in acute care w/ high O2 requirements
- Use in pts with low ABG’s
- MUST set up appropriately or will entrain CO2, can run at 10-25 LPM
13
Q
Pros of a NRB
A
- Fast delivery of high concentration of O2. Sources vary in actual O2 delivered (60-100%)
- Patients otherwise tethered to wall O2 supply become able to work on ambulation trials.
- Allows inhalation of high concentration of O2 from the reservoir bag and prevents re-inhalation of just-exhaled air, thus keeping the concentration of inhaled O2 consistently high.
14
Q
Cons to use a NRB
A
- Malfunctions of apparatus can lead to suffocation > STAY WITH THE PATIENT AT ALL TIMES
- Chronic CO2 retainers – these pts live at low o2 sat readings, <90% often around 85-90%. Their respiratory drive is maintained by higher CO2 levels, which if decreased, will in turn decrease respiratory drive and function
- Facial fractures and injuries > mask will not fit well
- Agitated pts > the mask must stay in place to be effective
15
Q
Describe heated high flow nasal cannula (AKA Aquinox)
A
- Because it is directly connected to the wall inlet there is no mixing with outside air
- Assists with improved gas exchange by saturating the dead space in the airway with higher oxygen concentrations
- Due to the high flow rates you can get a CPAP (continuous positive airway pressure) effect which helps to decrease atelectasis, improved perfusion and decreases work of breathing
16
Q
Pros of HHFNC
A
- Delivers a very accurate amount of FiO2 to the patient
- Humidified oxygen can assist with patient comfort as well as assist with preventing mucous plugging
- Allows patient to be able to eat/interact easier vs. BiPAP and other forms of facemasks
- Decreases patients work of breathing
- Can assist with avoiding more invasive ventilation if utilized early
17
Q
Cons of HHFNC
A
- Can be uncomfortable for the patient due to heavy tubing and larger nasal cannula
- Therapy is limited to the length of the system for mobilizing the patient as it is directly attached to the wall inlet flow O2 and if disconnected from the wall is unable to work and is not mobile.
18
Q
Therapy implications for HHFNC
A
- We need to know how much O2 the patient is on and how they have been tolerating- ex: do they desaturate with rolling in bed etc.
- According to the PADIS and MOVE+ criteria, an FiO2 of > 60% is contraindicated
- Determine if this patientcan mobilize on a different device (for example NRB?) as this particular device limits how far PT can mobilize; Discuss with RT
19
Q
Describe non-invasive positive pressure ventilation (NPPV)
A
- Mechanical ventilation using a mask instead of artificial airway
- Used when short-term ventilation is needed
- Results in less need for sedation & fewer complications than intubation & use of a ventilator
- If pt fails to improve/stabilize within a reasonable period of time, they should be intubated
20
Q
Indications for NPPV
A
- Exacerbations of chronic obstructive pulmonary disease (COPD) that are complicated by hypercapnic acidosis (PaCO2>45 mm Hg or pH <7.30)
- Cardiogenic pulmonary edema
- Hypoxemic respiratory failure
- May also be utilized to prevent respiratory failure after extubation.
- Absolute contraindication to NPPV is the need for emergent intubation.
21
Q
Relative contraindications for NPPV
A
- Cardiac or respiratory arrest
- Inability to cooperate, protect the airway, or clear secretions
- Severely impaired consciousness
- Nonrespiratory organ failure
- Facial surgery; trauma or deformity
- High risk for aspiration
- Anticipated prolonged duration of mechanical ventilation
- Recent esophageal anastomosis
22
Q
Describe CPAP (continuous positive airway pressure)
A
- A way of delivering PEEP (positive end-expiratory pressure)
- Maintains a set pressure throughout the respiratory cycle
- Can decrease atelectasis
- Increases surface area of alveoli
- Improves V/Q matching
23
Q
Descirbe a BiPAP (bilevel positive airway pressure)
A
- 2 lvls of pressure: IPAP (high amount of pressure applied when pt inhales) and EPAP (low pressure during exhalation)
- Generally prescribed for pts who cannot tolerate CPAP
- BiPAP may improve ventilation & vital signs more rapidly than CPAP in pts with acute pulmonary edema
24
Q
Pros of a CPAP/BiPAP
A
- Non-invasive
- Avoids intubation & complications associated with intubation
25
Cons of a CPAP/BiPAP
- Non-compliant/agitated pt may not tolerate
- Tissue injury where mask contacts (especially in elderly population)
- Hypotension (increases intrathoracic pressure & right ventricular after-load & reduces pre-load)
26
4 primary reasons for employing endotracheal intubation
- Upper airway obstruction
- Inability to protect the lower airway from aspiration
- Inability to clear secretions from the lower airways
- Need for positive pressure mechanical ventilatory assistance
27
The purpose of mechanical ventilatory support is to
- Meet physiologic needs in acute respiratory failure
- Protect the airway
- Relieve upper airway obstruction
- Improve pulmonary toilet
28
The main benefits of mechanical ventilation are the following
- Pt doesn't have to work as hard to breathe
- Pt's breathing has an opportunity to become normal
- Helps the pt get as much oxygen as he/she needs
- Preserves a stale airway
- Allows medications to work & the body to heal
29
Define ventilator terms
- Assist control (AC): each spontaneous respiratory effort generated by the pt, the machine delivers the preset tidal volume
- Synchronized intermittent mandatory ventilation (SIMV): pt is able to breath spontaneously b/w ventilator breaths
- Continuous positive airway pressure (CPAP): spontaneous mode of ventilation
- Positive end-expiratory pressure (PEEP): pos. pressure applied at the end of expiration during ventilation
- Pressure support ventilation (PSV): applies to spontaneous breaths only
- Tube compensation (TC): not a mode but a spontaneous breath type
30
PADIS guidelines for mobilizing ventilated patients
- RR = 5-40 breaths/min
- SpO2 ≥ 88%
- FiO2 <60% and PEP <10 (possibility to rupture alveoli if over 10)
- Limitations: Over-sedation of mechanically ventilated patients; Poor staff resources limiting the ability to deliver early mobilization
31
Describe a trach collar
- Aerosol-generating device from 21-100% FiO2
- Usually set 10 lpm and the entrainment collar is adjusted for the desired FiO2 though may be used up to 15 lpm
- The humidity device is connected to the flow meter, and wide bore tubing connects this to the patient’s mask. Wide bore tubing and the reservoir bag are placed in line to act as an oxygen reservoir to ensure an exact high FiO2 is delivered
32
Benefits of a trach collar
- Patient limited to length of tubing, however the patient can be switched to a Venturi mask to mobilize further. No limitation to distance of mobility
- Can assist in liquefying retained secretions
- Ideal for patients with tracheostomies because it allows for inspired air to be oxygenated, humidified and even heated if needed (main use of this device in our hospital)
33
Barriers of a trach collar
- Pt may need to be suctioned via sterile technique (RN or RRT will perform this)
- Other secretion management
34
Describe tracheostomy button or Passy-Muir valves
- Intermediate step between mechanical ventilation and spontaneous breathing in the process of weaning a patient from mechanical ventilatory support.
- The tracheostomy button permits the upper airway to be used for spontaneous ventilation while providing a means of maintaining the tracheostomy stoma as a direct access route to the lower airway until the patient no longer requires assistance to clear bronchial secretions.
- Both devices allow the patient to vocalize.
35
Describe inhaled nitric oxide (iNO)
- Last ditch effort to improve O2 when FiO2 is increasing with limited physiologic recovery
- Vasodilation of the small arterioles
- Less effective if >40ppm
- Typically seen in pts with severe pulmonary HTN
36
Describe an inhaled Flo-lan (epoprostenol or iEPO)
- Picks functioning alveoli & helps with the V/Q mismatch
- Need to watch for systemic hypotension & tachycardia as this can be possible with inhaled Flo-lan
- If you do not have experience with iNO or iEPO ask for help if attempt to mobilize
37
Describe extracorporeal membranous oxygenation (ECMO)
- VA: venous to arterial for cariogenic shock and/or cardiac arrest
- VV: venous to venous for respiratory failure
- Being used more commonly in managing ARDS
- Dislodgment of any of the cannulas may pose life-threatening risks
- Majority of pts need sedation & sometimes neuromuscular blocking agents (NBAs) during ECMO
38
Indications for ECMO
- Severe respiratory failure that is refractory to optimal mechanical ventilation and medical therapy
- Reversible respiratory failure including acute respiratory distress syndrome (ARDS) either due to
- COVID-19
- Bronchopulmonary aspiration
- Bacterial, viral or atypical pneumonia
- Barotrauma
- Acute or chronic interstitial pneumonitis
39
Describe VV ECMO
- Pt relies on their own hemodynamics
- Preferred type of ECMO as this is "resting" the lungs
- Deoxygenated blood is removed & passed through an oxygenator then returned to the R side of the heart
- Protek catheter is more stable as they sit deeper in the pulmonary anatomy
- Avalon catheter allows for more mobility but do have some inherent risk of rotating & losing directional flow
40
Precautions/contraindications for advancing functional mobility
- Untreated deep vein thrombosis
- Unstable vital signs
- Patient not able to follow commands, fully sedated
- High ventilatory support (for removing the patient from the ventilator for mobility)
- Contraindication: PEEP or CPAP > 10 cm H2O
- Precautions: PEEP or CPAP > 5 cm H2O, PAP > 50 cm H2O, minute ventilation > 15 L/min
- Other orthopedic, vascular, or neurologic injury that requires alternative bed activities
