T2 - Airway, Oxygen, Mechanical Ventilation (Josh) Flashcards Preview

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Flashcards in T2 - Airway, Oxygen, Mechanical Ventilation (Josh) Deck (93):
1

Difference between Hypoxemia and Hypoxia?

Hypoxemia = low levels of O2 in blood

Hypoxia = decreased tissue oxygenation

2

What is the goal of O2 Therapy?

use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects (O2 is a drug)

3

ABGs

Normal pH

7.35 - 7.45

less than 7.35 = acidic

greater than 7.45 = alkaline

4

ABGs:

Normal PaCO2

35 - 45

5

ABGs:

Normal PO2

90 - 100

6

ABGs:

Normal HCO3

22 - 26

7

What can happen with Oxygen-Induced Hypoventilation?

Hypercarbia = retention of CO2

CO2 Narcosis = loss of sensitivity to high levels of CO2

8

What is the amount that can be given via BNC?

1 - 6 L

9

O2 Devices:

What is the amount that can be given with a Simple Rebreather Mask?

6 - 10

**minimum of 5 L / min
** if less, go to BNC

10

O2 Devices:

What is the amount that can be given with a Non-rebreather Mask?

12-15 L/min

11

BNC:

What rates?

What O2 Concentration?

Rate = 1-6 L/min

O2 Concentration = 24 - 44%

12

Simple Facesmask:

What rates?

What O2 Concentration?

Rate = min of 5 L/min

O2 Concentration = 40-60%

13

Partial Rebreather:

What rates?

What O2 Concentration?

Rate = 6-11 L/min

O2 Concentration = 60-75%

14

With a Partial Rebreather, how much of the Tidal Volume is exhaled with each breath?

1/3

15

Which mask delivers the highest level of O2?

Non-rebreather Mask

rates of 12-15 L/min

16

A Non-Rebreather Mask can deliver what levels of FiO2?

greater than 90%

rates of 12-15 L/min

17

What would happen if the oxygen source should fail or both flaps of a Non-Rebreather Mask are in place?

Patient would not be able to inhale air, leading to CO2 buildup

18

What are the High-Flow delivery systems and what rates and concentation can they deliver?

Venturi Mask
Face Tent
Aerosol Maks
Tracheostomy Collar
T-piece

can deliver 24-100% at 8-15 L/min

19

Which delivery device is best for Chronic Lung Disease?

Why?

Venturi Mask

provides precise O2 concentration delivery

***switch to BNC during meals

20

What is a T-Piece used for?

Trachs

- provides humidified air

***Mist should be seen during inspiration and expiration

21

What is NPPV?

Noninvasive Positive-Pressure Ventilation

**uses positive pressure to keep alveoli open
**improves gas exchange without airway intubation

22

What are examples of NPPV?

BiPAP

CPAP (Continuous Positive Airway Pressure)

23

What are CPAPs used for?

Atelectasis after surgery

Cardiac-induced PE

Sleep Apnea

24

What is TTO?

Transtracheal Oxygen Delivery

**small flexible catheter is passed into trachea through small incision

**long-term

**avoids irritation that nasal prongs can cause

25

What are the two ways we can reposition client to maintain patent airway?

Head Tilt-Chin Lift Method

Jaw Thrust Method
***for people in any accident where possible trauma to spinal cord or neck

26

What is the benefit of the Oropharyngeal Airway?

prevents airway obstruction from tongue

***gotta be unconcious b/c gag reflex will be stimulated

27

Measuring appropriates size for Oropharyngeal Airway

Place the oropharyngeal airway along the outside of the jaw with one end of the airway at the bottom tip of the ear.

Close the mouth and bring the other tip of the airway toward the corner of the mouth.

The airway should reach from the bottom tip of the ear to the corner of the mouth.

Proper placement: the tip of the airway lies above the epiglottis at the base of the tongue

Can cause obstruction if incorrect size

28

When are Oropharyngeal Airways used?

to ease breathing in ICU for a dying patient

29

How do you measure correct size for Nasopharyngeal Airway?

Hold the airway against the side of the face and ensuring it extends from the tip of the nose to the earlobe

Proper placement: the tip of the airway lies above the epiglottis at the base of the tongue

Lubricate prior to placement

30

When do we want to use a long-term Trach?

if they need it for longer than 21 days

***If less, use Oral or Nasal

31

When inserting an Endotracheal Tube (ETT), what do we use to confirm placement?

CO2 Detector

Xray for confirmation

32

ETT:

Why do we measure placement by the teeth/gums and not the lips?

lips can swell and give false impression of dislodgement or movement

33

ETT:

How is Correct Placement confirmed?

Auscultate x 5

Inspect Chest Expansion

End-Tidal CO2 Detector

CXR

34

ETT:

Why do we ausculatate 5 x's for confirmatin of placement?

to make sure we are in airway and not lungs

***listen in epigastric area first to make sure not in esophagus

***then listen abdomen, anterior and laterally on each side

35

ETT:

Why do you want to inspect chest expansion to confirm placement?

make sure you're inflating both lungs and not just one

36

ETT:

With CXR, what depth are we looking for in placement of the tube?

3-4 cm above carina (where trachea bifurcates into right and left bronchus)

***we don't want it into one of the bronchi

37

ETT:

What cuff pressure are we looking for?

14-20 mmHg

38

ETT:

Should we be able to hear coughing or gagging if tube places properly and pressure is correct?

No

Air should not be able to leak around the sides of the tube and through the vocal cords

if they make sounds, then we know that air is leaking around the pressure cuff

39

ETT:

Don't use --- in the ETT if suctioning?

saline

***will cause more damage to trachea

40

Suctioning:

What should we do before suctioning?

hyperoxygenate patient

**turn FiO2 machine up to 100% for a few mins

41

What are some complications from suctioning?

Hypoxia

Tissue (Mucosal) Trauma

Infection

Vagal Stimulation and Bronchospasm

Cardiac Dysrhythmias (PVCs) from Hypoxia

42

Which cardiac rhythm is associated with hypoxia?

PVC

43

Extubation Process

Hyperoxygenate Patient

Sucntion ET and Oral Cavity

Rapidly deflate ET cuff

Remove tube at PEAK INSPIRATION

Instruct patient to cough

Monitor patient q 5 mins and assess for resp. distress

44

--- is a surgical incision into trachea for purpose of establishing an airway

--- is the stoma (opening) that results from tracheotomy.

Tracheotomy

Tracheostomy

45

Where is the incision for the Tracheotomy done?

2nd, 3rd, and 4th Tracheal Rings

46

What will laryngeal stenosis look like?

hoarse voice

47

Why must tracheostomy air be humidified and warmed?

it bypasses the nose, which normally does these things

48

What is one way to keep secretions thin with an trach patient?

keep them adequately hydrated

49

Tracheostomy:

What are some causes of hypoxia?

Ineffective oxygenation before, during, and after suctioning

Use of catheter that is too large for the artificial airway

Prolonged suctioning time

Excessive suction pressure

Too frequent suctioning

50

Tracheostomy:

What should we do to prevent aspiration?

elevate HOB for at least 30 mins after eating

51

Tracheostomy:

What can be done to promote Bronchial and Oral Hygiene?

Turn/Reposition every 1-2 hrs

Encourage early ambulation

Coughing and Deep Breathin

Avoid alcohol wipes for oral care (use chlorhexidine instead)

52

Tracheostomy:

How and when is weaning accomplished?

cuff is deflated when patient can manage secretions and does not need assisted ventilation

weaning involves a gradual decrease in tube size leading to ultimate removal of tube

53

Types of Ventilators

Negative Pressure

Positive Pressure
- Pressure-cycled
- Time-cycled
- Volume-cycled

54

Mechanical Ventilator:

What are the Modes of Ventilation?

Assist-control Ventilation (AC)

Synchronized Inermittend Mandatory Ventilation (SIMV)

Bi-level Positive Airway Pressure (BiPAP)

Others

55

Mechanical Ventilator:

What are the ventilator controls and settings?

Tidal Volume (Vt)

Rate (breaths/min)

Fraction of Inspired Oxygen (FiO2)

PIP

CPAP

PEEP

Flow and other settings

56

Modes of Ventilation:

What is AC (Assist Control) or CMV (Continuous Mandatory Ventilation)?

Delivers preset number of breaths at tidal volume

If pt. initiates breath, machine delivers a preset tidal volume for every breath

***It Vt is set at 600, they will get 600 for every breath
***Number set is minimum (ex: if 10, he will get 600 Vt 10 tims a minute if he breathes less than that....if he breathes more (say 20 x's) then he gets 600 Vt 20 x's

57

Modes of Ventilation:

What is PRVC (Pressure-Regulated Volume Control)?

combo of volume and pressure features

- Delivers a preset Vt using the lowest possible airway pressure
- Airway pressure will NOT exceed preset maximum pressure limit

****prevents injury to lungs
****used with ARDS because lungs become stiff and non-compliant

58

Modes of Ventilation:

What is BiPAP (Bi-level Positive Airway Pressure)?

Pre-set inspiratory pressure

Expiratory pressure
- two levels
- a range for Positive End Expiratory Pressure (PEEP)
***from HIgh PEEP to Low PEEP

59

Modes of Ventilation:

What is SIMV (Synchronous Intermittent Mandatory Ventilation)?

Delivers preset number of breaths at preset tidal volume

***if patient initiates breath, machine allows patient to breath in OWN TIDAL VOLUME

***your own breaths are the Vt

***requires you to work harder than Assist Control

60

Modes of Ventilation:

What is CPAP (Continous Positive Airway Pressure)?

Patient initiates own breath

Machine delivers constant positive pressure

61

Ventilator Settings:

What is Pressure Support?

a set amount of pressure delivered when patient initiates own breath

assists mvmt of air through ventilator tubing in order to AUGMENT PATIENTS OWN TIDAL VOLUME

****WORKS AT BEGINNING OF INSPIRATION

62

Ventilator Settings:

What is PEEP?

Positive End Expiratory Pressure

** positive airway pressure appled at end of expiration to KEEP ALVEOLI OPEN and facilitate O2 transport

WORKS AT END OF EXPIRATION

63

PEEP vs. Pressure Support

Which one works at beginning of inspiratoin?

Pressure Support


***PEEP works at end of EXPIRATION

64

When would PEEP be used?

used in atelectasis (when you need more alveoli participating in exchange)

65

Ventilator Settings:

What is Tidal Volume?

amount of air it takes to inflate lungs with each breath

takes approximately 10-15 mL/kg

66

Ventilator Settings:

What is Minute Ventilation?

amount of gas moved in or out of lungs per minute

RR x TV = MV

ex: 12 bpm x .600 TV = 7.2 L/min

Normal is 5-8 L/min

67

Why is Minute Ventilation Important?

it is the assessment of the work of breathing

normal is 5-8 L/min

RR x TV = MV

68

Ventilator Settings:

What is I:E Ratio?

Inspiration to Expiration Ratio

1:2 is normal

69

What would we set the I:E Ratio for COPD patient?

Longer (1:4) to prevent 'Breath Stacking'

70

Ventilator Settings:

What is PIP?

Peak Inspiratory Pressure (PIP)

**amount of pressure it takes for ventilator to deliver TV or breath

***changes from breath to breath

71

What does an increased PIP indicate?

there is not a clean airway

**suction or check to see if kink or patient biting it

**Mucous plug number one cause

72

Ventilator Settings:

What is FiO2?

Fraction of Inspired O2

- percentage or fraction of oxygen delivered by the ventilator

***shows us how much of the work the ventilator is doing

73

Troubleshooting Alarms:

What can cause a High Pressure Limit?

Circuit tubing kinked

Water collecting in dependent tubing

Fighting vent (breath stacking)

Airway secretions, coughing

ETT in Right Bronchus (too far down)

Decreased Lung Compliance
**ARDS
**Tension Pneumothorax
**Pumonary HTN

74

Troubleshooting Alarms:

What can cause Low Pressure Limit?

Tubing disconnected

Circuit leak

Cuff deflated

75

Troubleshooting Alarms:

What can cause Low Exhaled Tidal Volume?

Leak in system

Poor cuff inflation

Leak through chest tube

76

Troubleshoot Alarms:

What can cause Temperature Alarm?

Sensor malfunction

Sensor pickup up outside airflow

77

Troubleshooting Alarms:

What can cause Apnea Alarm?

Sedation

Neurologic

Metabolic

78

Troubleshooting Alarms:

What can cause High Respiratory Rate Alarm?

Not tolerating weaning

Neurologic / Metabolic

Anxiety

Pain

79

Troubleshooting Alarms:

What can cause Mechanical Ventilator Failure?

Check outlet (red outlet goes to backup generator)

Bad machine

80

What can we do to prevent complications from Mechanical Ventilation?

Plateau pressure kept greater than 32 cm H2O

PEEP should be used

Vt set at 6-10 mL/kg (as low as possible to prevent injury)

81

Ventilator Induced Lung Injury:

What is Barotrauma?

excessive pressure in the alveoli

82

Ventilator Induced Lung Injury:

What is Volutrauma?

excessive volume in the alveoli

83

Ventilator Induces Lung Injury:

What is Atelectrauma?

shearing due to repeated opening and closing of the alveoli

84

Ventilator Induced Lung Injury:

What is Biotrauma?

Inflammatory immune response to ventilator

85

What are some Cardiovascular complications from Ventilator?

Cardiovascular Compromise:

- Increased intrathoracic pressure
- decreases venous return, decreasing preload, decreasing CO and BP
- Tachycardia to compensate
- Hepatic and Renal dysfunction
- Impairment of cerebral venous return -- increasing ICP

86

What are some GI Distrurbances from Ventilator?

Gastric Distenstion

Hypomotility

Constipation

87

How can PEEP cause a pneumothorax?

too much pressure causing the lungs to collapse

88

Nosocomial Pneumonias account for --- of all hospital infections and --- of all MICU infections.

15%

27%

***risk factor is 6-21 x's more for ventilated patient than non-ventilated

89

Nosocomial Pneumonias:

Within 48 hrs of intubation, which bacteria commonly colonizes in the URT?

Gram Negative bacilli

90

What can we do to prevent Ventilator Associated Pneumonia (VAP)?

HOB 30-45 degrees

ETT with a dorsal lumen provides continuous suction above the cuff

Oral care

Handwashing

****first 24 hrs is most critical

91

Proper oral care to prevent VAP?

use BRUSH instead of the soft swab once a shift with chlorahexadine solution

***use soft swab q 2 hrs for oral airway

92

What are Ventilator Bundles?

bundle of orders for nursing and resp. therapy for a patient on ventilator to prevent complications

93

What are some of the things we do in Ventilator Bundel orders?

VAP precautions

DVT precautions

Gastric Reflux prevention

Sedation vacations

Evaluations of readiness to wean from ventilator