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Review Flashcards

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1
Q

Normal Neonatal Ti

A

0.3-0.4

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2
Q

Normal Vt for Neonatal

A

5 ml/kg

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3
Q

Venoarterial (VA) ECMO

A

Will offload both the heart and the lungs

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4
Q

Single Site Approach to Venovenous ECMO Cannulation

A

A dual lumen cannula is inserted into the jugular vein

Venous blood is withdrawn through one lumen that has ports in both superior and inferior vena cava

Reperfusion will occur in second lumen located in right atrium and will dump blood into the right ventricle, this is designed to reduce recirculation of blood

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5
Q

How Long is ECMO Used for Compared to Cardiopulmonary Bypass

A

ECMO is a longer therapy compared to cardiopulmonary bypass

Cardiopulmonary bypass is only used for hours

ECMO can be used for up to 10 days

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6
Q

What is the Main Reason Why ECMO is Use in Neonates

A

PPHN which results from different diseases such as pneumonia, MAS, RDS

CHD

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7
Q

What is the Main Reason Why ECMO is Use in Adults

A

Severe Asthma and ARDS

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8
Q

What are the risk factors that are associated with ECMO

A

Bleeding

Thrombosis

Infection

DIC

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9
Q

Nova Lung

A

Provides pumpless arterio-venous extrapulmonary lung support, because it is pumpless the blood pressure of the patient is needed to circulate the blood

Uses diffusion to provide oxygenation and ventilation

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10
Q

Venovenous (VV) ECMO

A

Will only support the lung

Venous blood will be divided into two semi-permeable membranes, and gas exchange will occur along the membrane

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11
Q

Indication for ECMO

A

Potentially reversible severe cardiac or pulmonary failure that is unresponsive to other treatment

Hyoxemic Resp Failure

Hypercapnic respiratory failure with an arterial pH <7.20

Refractory cardiogenic shock

Cardiac arrest

Failure to wean from cardiopulmonary bypass after cardiac surgery

As a bridge to either cardiac transplantation or placement of a ventricular assist device

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12
Q

Independent Lung Ventilation

A

A double lumen will allow for separate ventilation of each lung which can be done synchronously or asynchronously

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13
Q

Prone Positioning Indications

A

Severe ARDS-Main

Acute lung injury where there is V/Q mismatching

Cardiogenic pulmonary edema

Pneumonia

Pulmonary embolism

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14
Q

Prone Positioning Absolute Contraindication

A

Acute Bleeding

Spinal instability

Pregnancy in the third trimester

Increased ICP

Traction

Weight > 136 kg

Unstable sternum (open heart surgery)

Ventricular assist device

Intraortic balloon pump

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15
Q

Prone Positioning Relative Contraindication

A

Multiple trauma

Continuous renal replacement therapy

Temporary pacemaker

Hemodynamic instability

Large abdomen

Gross ascites

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16
Q

How to Position the Prone Patient

A

Reverse trendelenburg, 30 degrees if possible in order to limit risk of aspiration

Use pillows/positioning devices to maximize diaphragmatic excursion

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17
Q

According to AHS How Long Should We Prone

A

Prone 3 hours and supine 1

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18
Q

Discontinuation of Proning

A

FiO2 < 0.60

Deterioration of patient status related to prone position

Positioning demonstrates no improvement in patient status or becomes no longer beneficial

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19
Q

Airway Pressure (Paw)

A

Paw=Ptp - Ppl

Reflects pressure required to inflate both the lungs and the chest wall

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20
Q

Paw Measuremnets

A

Plateau pressure during inspiratory pause

Total PEEP during an expiratory

So Paw = Palv during pause maneuvers because there is no flow

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21
Q

Drawback of Airway Protective Ventilation

A

Assumes that pleural pressure is negitable

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22
Q

Pleural Pressure (Ppl)

A

Pressure in pleural space and will be affected in intra-abdominal pressure and decrease in chest wall compliance

This can be measured through esophageal pressure monitoring,

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23
Q

What will Increase Ppl

A

Anything that will increase intra-abdominal pressure

Obesity

Ascites

Ileus

Bowel Edema

Post Fluid Resuscitation

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24
Q

Transpulmonary Pressure

A

Requires the measure of esophageal pressure through a esophageal balloon

The Peso is though to represent Ppl

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25
Esophageal Balloon Pressure Measurement
The catheter is measuring the pressure in the thoracic cavity and you need to subtract this from the pressure that the ventilator is giving you can isolate the pressure in the lungs Ptp = Paw – Pe
26
Inserting Esophageal Catheter
Insert 60 cm and then pull back to 40 cm looking for cardiac oscillation Can push on belly as a check to see temp spike in pressure
27
Performing an Esophageal Pressure Monitoring
Do an inspiratory hold to determine Ptp which can be used to make sure that the pressures are \<30 Do an expiratory hold to see if Ptp is positive which is needed in order to maintain recruitment of alveoli
28
Bladder Pressure and Abdominal Pressure
Bladder pressure and abdmonial pressure are correlated and not predictive When there is an increase in bladder pressure that is a red flag
29
Lung Volume Recruitment Manoeuvre
LVRM are used to open up alveoli with high inspiratory pressure and determine appropriate PEEP One way to perform a LVRM is to use a high PEEP of 30-40 for 30-60 seconds and make sure to monitor vitals while you are doing this
30
LVRM Indication
CXR with bilateral infiltrates (AIL or ARDS) Atelectasis Increase OI High PEEP Suctioning/Discontection
31
Contraindication to LVRM
Pulmonary air leaks: Recent, active pneumothorax, PIE, etc Bronchopleural fistula Hemodynamic instability (eg. low BP) Head Injury Obstructive lung disease Pregnancy
32
When to Stop a LVRM
SpO2 falls \< 80% MAP \< 60 or 20% change from baseline HR \< 60 or 20% change from BL New arrhythmia
33
APRV Definition
Inverse ratio, pressure controlled, and time cycled ventilation mode
34
Advantages of APRV
Lung protective, and can help oxygenation and ventilation Easy to manipulate MAP and I:E May be more comfortable as allow for spontaneous breathing (positive effect comes from spontaneous breathing)
35
Disadvantages of APRV
May result in muscle atrophy
36
Link Between Thigh and Expiratory Flow Rate
Tlow begins once Phigh is over and at this point the expiratory flow rate is highest at this point and equal to PEF Tlow should terminate at the time that PEF is reduced to 25-50% of peak Expiratory flow is not finished before inhalation occurs so that PEEP can be maintained
37
Total PEEP in APRV
Plow + Auto PEEP
38
Frequency in APRV
Frequency is 60 seconds divided by the sum of Tlow plus Thigh ## Footnote APRV is most successful with a limited number of releases. Ventilator frequency should remain around the 10- 12 range. Increases outside this range promotes derecruitment, and risks a return to refractory hypoxaemia.
39
APRV Settings When Switching From Conventional Ventilation
Phigh: Match Pplat on current mode (max 30 cmH2O) Plow: Set to 0 cmH2O Thigh: 4.0 sec Tlow: 0.5-1.0 sec (often 0.8 sec)
40
I:E in APRV
4:1 or greater We want to spend 90-95% of the time in Phigh
41
APRV Setting When Starting On APRV
Phigh: Set at 30 cmH2O Plow: Set to 0 cmH2O Thigh: 4.0sec Tlow: 0.5-1.0 sec (often 0.8 sec)
42
Increasing Ventilation When On APRV
Decreasing PaCO2 ## Footnote Weaning sedation/increasing spontaneous ventilation Increase Phigh (increase your Vt and MV) Decrease Thigh Optimize Tlow to between the 25-50% Increase Tlow
43
Increasing Oxygenation in APRV
Increase FiO2 Increase Phigh Increase Thigh Decrease Tlow
44
Weaning of APRV
Weaning is achieved through decreasing Phigh and increasing Thigh to get a low CPAP The minute volume generated by release volumes decreases and is gradually supplemented by increased spontaneous minute volume, until the patient has essentially been weaned to pure CPAP.
45
Barriers to the Use of APRV
**Lack of clinician knowledge and comfort** Concerns about over-distension/over-stretching No RCT showing improved outcome in humans (yet May be contraindicated in air leak syndromes and conditions of TBI/high ICP due to hypercapania
46
Tube Compensation
Nullify the resistance imposed on the tube to help facilitate a proper SBT Will be similar to pressure support Reduce of risk of air trapping Will set % of compensation you want and whether you want inspiratory and/or expiratory help
47
Assessing Optimal Tlow in APRV
Tlow should be re-evaluated every 1-2 hours for the first six hours as that is when the lung will undergo the most recruitment and we need to ensure that volumes do not exceed 8ml/kg Tlow should also be re-evaluated after a change in the pressure setting
48
Why is ARPV Helpful in ARDS
ARDS reduces FRC and compliance and increases WOB Applying Phigh will restore FRC and create a better pressure volume relationship to help faciliate spontaneous ventilation and oxygenation
49
Mean Airway Pressure in APRV
Mean Airway Pressure in APRV= _(Phighx Thigh) + (Plow x_ _Tlow__)_ (Thigh+ Tlow)
50
Timing of APRV
Most effective as treatment for ARDS when used as initial mode of ventilation May be used with the spontaneous breathing COPD pt
51
High Frequency Ventilation
Frequencies \>150 bpm Tidal volumes are so small that they can be smaller than deadspace
52
Frequency of HFV
Frequencies is measured in Hertz (Hz) which is cycles per second 1 Hz=1 cycle/sec=1 breath per second=60 bpm
53
What Are the Indications for HFV
Acute Lung Injury (Severe Oxygenation Failure) Ventilation failure Upper airway surgery and bronchoscopy BP Fistula or pulmonary air leaks in neonates (eg. PIE)
54
High Frequency Jet Ventilation (HFJV)
Passive exhalation which means there is the risk of breath stacking Combines the use of a jet ventilator and a conventional ventilator The conventional vent provides the PEEP (which = MAP) and +/- sigh breaths and then the jet ventilator will pulse above this
55
High Frequency Oscillation (HFO)
Most common **Active exhalation**
56
MMV
When the patient is breathing above the set MV the vent will only deliver pressure supported breaths When the patient is not meeting the set MV the vent will deliver mandatory breath
57
58
ASV Breath
Based on set % MV Mandatory breaths will be PRVC Spontaneous breaths PS and volume targeted
59
% MV for ASV
Based on 100 ml/kg IBW for 100% setting Normal Pt 100% COPD 90% ARDS 120% Extra for hyperthermia with 10% extra per oC increase Extra for altitude with 5% per 500 m above sea level Add 10% when an HME has been added
60
Managing Severe Acidosis with ASV
Increase PEEP and/or FiO2 Increase %MV
61
Managing High Oxygenation Needs in ASV
Increase PEEP and FiO2
62
Managing High Respiratory Drive in ASV
Increase %MV
63
Managing Respiratory Alkalosis with ASV
Decrease %MV
64
Basic Theory of Jet Ventilation
The small Vt will move through the deadspace instead of pushing the deadspace in Exhaled gas will cycle out through counter current
65
Equitment Needed for Neo and Ped Transport
O2 Supply and blender and O2 analyzer Mech vent Mechanical Resuscitator Pressure monitor O2 monitor (X2) ECG Suction Intubation Equitment Feeding Tube O2 hood O2 tubing Hand held neb with tubing
66
Tank Calculation
Duration of Flow = Oxygen Tank Conversion Factor \* Remaining Tank Pressure (psi) / Continuous Flow Rate (L/min)
67
Oxygen Cylinder Conversion Factors D Tank
D Tank = 0.16
68
Oxygen Cylinder Conversion Factors E Tank
E Tank = 0.28
69
Oxygen Cylinder Conversion Factors G Tank
G Tank = 2.41
70
Oxygen Cylinder Conversion Factors H/K Tank
H/K Tank = 3.14
71
Oxygen Cylinder Conversion Factors M Tank
M tank = 1.56
72
Total Arterial O2 Content
CaO2= (1.34 x Hb x SpO2) + (PaO2 x 0.003)
73
How to Determine Pt Inspiratory Flow
Flow= Volume (L)/time (min)
74
Determining the total flow in a high flow delivery device
If air/O2 is for example 30 then it is 8:1 so for every 1 litre of oxygen 8 L is being entrained into the device for total flow add the two toegther (=9) and then multiple by the set flow
75
Calculating Flow in Liquid Oxygen System
Gas Remaining= (Liquid Weight [lb]) x 860/ 2.5 L/Ib Duration of Contents (min)= Gas Remaining (L)/ Flow (L/min) Remeber 1 L of Liquid O2 = 2.5 lb
76
Rigid Bronchoscope
Mainly used for removal of foriegn bodies
77
Parts of the Flexible Bronchoscope
**Light Transmission Channel:** Light source at distal end of bronchoscope **Visulization Channel:** Has lens to produce an image at the proximal end **Working Channel:** Suction, tissue sample, O2 administration
78
Indications for Bronchoscope
Bronchogenic Carcinomas Investigation Therapeutic
79
80
Absolute Contrindications for Bronchoscope
—No consent —No driver —No garage —No ability to oxygenate/ventilate
81
Relative Contrindicationsfor Bronchoscope
—Uncontrolled bleeding —Uncontrolled severe COPD —Uncontrolled hypoxemia —Unstablehemo-dynamics (arrhythmias etc.)
82
Complications of Bronchoscope
—Hypoxemia & hypercapnea —Vasovagal response (Hypotension, Bradycardia) —Airway irritation —Epistaxis —Pneumothorax —Hemoptysis
83
—Anticholinergic “drying” agent to decrease secretions
—Atropine —Glycopyrrolate
84
Bronchoscope Premedication Administration
—Prior to the bronchoscopy procedure, outpatients are admitted to a day stay unit & nursing staff help prepare them… —Ensuring the consent form is signed —Inserting an IV —Premedicatingif called for: * —Morphine * —Ventolin: prophylactic prevention of bronchospasm * —Atropine: decreases bronchial and salivary secretions & helps prevent bradycardia from excessive vagal stimulation
85
Bronchoscope Brushing
—Usually performed for cytology or histology analysis
86
Bronchoscope Transbronchial Needle Aspiration
—Used to sample areas on other side of bronchial wall (extrabronchialor transbronchial) —Performed under fluoroscopy —Advanced through suction channel with needle retracted —On physician’s request, needle advanced exposing it past sheath —Manipulated by thumb control —Physician darts desired site —Syringe attached to proximal end of the needle to aspirate sample
87
Bronchial Alveolar Lavage
—Performed when area sampled distal to segmental or sub-segmental bronchi in which bronchoscope is resting —Bronchoscope advanced and wedged totally occluding airway —On physician’s request 6Occ of sterile NS is instilled through suction channel —Often 30cc aliquots —Sample aspirated and collected in BAL trap (70ml) —Much of saline instilled recovered —If \< 35 cc of NS recovered, another 60 cc of sterile NS instilled and aspirated again —Recovered sample contain cells for analysis —Samples sent to microbiology —Visually inspect for foamy head on sample indicating presence of surfactant and indicating good sample
88
BLES Dosing
5 ml/kg

Interventions 3 (34 decks)

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