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Pilbeam's Mechanical Vent Chapter 4
Terms in this set (91)
What are ethical contradictions to invasive ventilation?
1. When it is contrary to the patient's advance directive.
2. If it medically pointless and futile
3. No chance the ventilation would extend the person's quality of life in a meaningful way.
When should NIV(Non-Invasive Ventilation) be changed to Invasive Ventilation?
Respiratory rate >35 pm
Severe dyspnea with use of accessory muscles and/or paradoxical breathing
Life-threatening hypoxemia: Pa02<40 mmHg or Pa02/Fi02 <200
Severe acidosis (pH <7.25) and hypercapnia (PaC02 >60 mmHg)
Failure of NIV
Sepsis, Pulmonary Emoblism, Barotrauma, Meassive Pleural Effusion, or Metabolic abnormalities
Acute Respiratory Failure (ARF)
Any condition in which respiratory acitivity is completely absent or is inadequate to maintain oxygen uptake and carbon dioxide clearance
What is NIV the treatment of choice of?
Acute-on-chronic respiratory failure
How does NIV help acute-on-chronic respiratory failure?
It reduces the need for intubation, reduce complications of ventialtion, shortens the hospital stay, and reduces mortality rates.
What is an indication for NIV?
Respiratory rate >25 bpm
Moderate to severe acidosis: pH 7.25 to 7.30; PaC02 45-60 mmHg
Moderate to severe dyspnea with use of accessory muscles and paradoxical breathing pattern
How many indications are needed for NIV?
What therapies help treat a patient with hypoxemia?
Placing the patient in Fowler's position
Administering Oxygen therapy
What must a clinician consider before ventilating and intubating a patient's lungs?
Patient's medical history
Lung mechanics measurements
What are indications for Mechanical Ventilation in Adult patients with Respiratory Failure?
1. Apnea or impending respiratory arrest
2. Acute excaerbation of chronic onbstructive pulmonary disease with dyspnea, tachypnea, and acute respiratory acidosis and at least one:
a) Acute cardiovascular instability
b) Altered mental status or uncooperative patient
c) Inability to protect the lower airway
d) Copious or viscous secretions
e) Abnoramalities of the face or upper airway that would prevent effective NIV
3. Acute ventilatory insufficiency in cases of neuromuscular diseases with acute respiratory acidosis, progressive decline in vital capacity, or progressive declince in MIP to below -20 to -30 cm H20.
4. Acute hypoxemic respiratory failure with tachypnea, respiratory distress, and persistent hypoxemia despite administering a high Fi02.
5. Need for ET tube to maintain to protect the airway or to manage secretions
In what case do you NOT intubate a patient for invasive positive pressure ventilation until other therapies have been attempted?
Dyspnea, acute respiratory distress
Acute excaerbation of COPD
Acute severe asthma
Acute hypoxemic respiratory failure in immunocompromised patients
Hypoxemia as an isolated finding
Traumatic brain injury
What is the standard criteria to institute Mechanical Venitilation?
Apnea or presence of breathing
Acute ventilatory failure
impending ventilatory failure
Reffractory hypoxemic respiratory failure with increased WOB on inaffective breathing pattern
What value indicates a need for invasive ventilation?
There is no single value of pH, Pac02, or Pa02 that indicates a need for invasive ventilation.
In whaat conditions is it critical to protect the patient's airway?
Stroke, drug overdose, cerebral damage, copious secretions, vscous secretions.
How do you test a patient for dehydration?
Pinch the skin on the back of the patient's hand. If the skin returns to its normal position, it is normal. If the skin remains puckered, it is decreased and the patient probably is dehydrated.
What is the treatment for arterial hypoxemia caused by hypoventilation?
Increase Fi02, increase alveolar ventilation
What is the treatment for arterial hypoxemia caused by low ventilation/perfusion ratio?
Increase Fi02, CPAP
What is the treatment for arterial hypoxemia caused by intrapulmonary shunt?
Increase Fi02, CPAP
What is the treatment for arterial hypoxemia caused by diffusion defect?
Increase Fi02, steroids, diuretics
What is the treatment for arterial hypoxemia caused by low barometric pressure?
Descend to lower altitude
What is the treatment for arterial hypoxemia caused by low inspired oxygen concentration <21%?
What causes hypoxemia when Pa02 is low and PA-a02 is high?
Shunt, diffusion defects, and V/Q mismatch
PaC02 may be lower than normal(hyperventilation) to compensate for hypxemia
What can be used to evaluate a patient's oxygenation status?
What is the normal range for Pa02/PA02?
When do you need to treat hypoxemic respiratory failure with mechanical ventialtion insteasd of PEEP or CPAP?
With increased WOB or a rising PaC02 and falling pH
Arterial Oxygen Content Calculation
Ca02=(Hb x 1.34) x Sa02) + (Pa02 x 0.003)
What is the best single indicator of adequate ventilation?
What does an elevated PaC02 suggest?
Dead space is increased relative to tidal volume
What is the normal range for Vd/Vt?
0.3 to 0.4
What is a critcal value for dead space?
What are common causes of an increased dead space?
Pulmonary thromboemboli, pulmonary vascular injury, and regional hypoperfusion
What are the indicators of the severity of acute hypoxemic respiratory failure?
Pa02 and Sp02
What is a normal Pa02
What indicates refractory hypoxemia or hypoxemic respiratory failure?
Pa02 <70 mm Hg, Sp02 <90% on and oxygen mask > or = to 0.6(60%)
What value of PaC02 indicates scute hypoventialtion or acute hypercapnic respiratory failure?
PaC02 > 55 mmHg and a decreasing pH < 7.25
MIP and VC
What is used to assess respiratory muscle strength of patients with nueromuscular disease?
Normal MIP value
-50 to -100 cm H20
the volume of air that can be maximally exhaled following a maximum inspiration
65 to 75 mL/kg of IBW; less than 10 to 15 mL/kg are not adequate to produce a cough or maintatin normal ventialtion
What is the primary purpose of ventilation?
To maintain homeostasis
What is homeostasis?
A consistency or imbalance in the internal enviroment of the body. It is maintained by adaptive responses that promote survival and well-being
What are the physiological objectives of mechanical ventilation?
To support or manipulate pulmonary gas exexchan, teduce the work of breathing, and to increase lung volume
What are the clinical objectives of
Reverse acute respuratory failure
Reverse respiratory distress
Prevent or reverse atelectasis and maintain FRC
Reverse respiratory muscle fatigue
Permit sedation or paralyis or both
Reduce systemic or myocardial oxygen consumption
Minimize associated complications and reduce mortality
What is a result of respiratory failure?
Coma and death
Initial assessment of respiratory distress
Determine patient's level of consciousness
Assess the appearance and texture of skin
Evaluate the patient's vital signs
What is sudden onset of dyspnea accompanied with?
Physical signs of respiratory distress
How do patients experiencing respiratory distress appear?
Anxious, eyes wide open, forehead furrowed, ans nostrila flared
Patients in respiratory and cardiac distress
May appear ashen, pale, cyanotic, and sometimes using their accessory muscles
Patients in severe respiratory distress
Complain of not getting enough air, may see the supraclavicular notch indented during inspiration, paradoxical or abnormal movement of thorax and abdomen, abnormal breath sounds, tachycardia, arrhythmias, and hypotension
Panic attack can show signs of respiratory distress. The patient can be relieved from the distress by
Being calmed and questioned by the clinician
Acute respiratory failure
No respiratory activity or insufficient to maintain adequate oxygen and carbon dioxide clearance
Clinically ARF is recognized as
The inability to maintain Pa02, PaC02, and pH at acceptable levels; Pa02 below normal range for the patient's age under ambient conditions, a PaC02 >50 mmHg amd rising, falling pH of 7.25 or lower
What are the two forms of acute respiratory failure?
Hypoxemic respiratory failure and hypercapnic respuratory failure
What is hypoxemic respiratory failure a result of?
Severe ventilation/ perfusion mismatching
What can hypoxemic respiratory failure occur with?
Diffusion defects, right-to-left shunting, alveolar hyperventilation, aging, and inadequate inspired oxygen
Acute hypoxemic respiratory failure
Acute life threatening or vital organ threatening tissue hypoxia
What can hypoxemic respiratory failure be treated with?
PEEP with oxygen or CPAP
What does the ventilatory pump consist of?
Respiratory muscles, thoracic cage, and nerves controlled by the respiratory centers in brainstem
What disorder can lead to pump failure?
Central nervous system disorders
Disorders that increase the work of breathing
Which CNS disorders reduce the drive to breathe and are associated with hypoventilation and respiratory failure?
Depressant drugs (barbiturates, tranquilzers, narcotics, and general anesthetic agents)
Brain or nrainstem lesions (stroke, trauma to the head or neck, cerebral hemorrhage, tumors, spinal cord injury)
Sleep apnea syndrome caused by idiopathic central alveolar hypoventilation
What CNS disorders increase the drive to breathe and are associated with hypoventilation and respiratory failure?
Increased metabolic rate (increased C02 production)
Anxiety associated with dyspnea
What Neuromuscular disorders are associated with hypoventilation and respiratory failure?
Paralytic disorders (Myasthenia gravis, tetanus, botulism, Guillain-Barre syndrome, poliomyelitis, muscular dystrophy, amytotrophic lateral sclerosis)
Paralytic drugs (curare, nerve gas, succinylcholine, intsecticides, non depolarizing neruromuscular blocking agents)
Drugs that affect the neurosmuscular transmission ( aminoglycosteroids, calcium channel blockers)
Impaired muscle function (electrolyte imbalances, malnutrition, peripheral nerve disorders, atrophy, fatigue, chornic pulmonary disease with decreasing capacity for diaphragmatic contraction as a result of air trapping)
What disorders that increase the work of breathing are associated with hypoventilation and respiratory failure?
Pleura-occupying lesions (pleural effusions, meothorax, empyema, pneumothorax)
Chest wall deformities (flail chest, rib fracture, kyphoscoliosis, obesity)
Increased airway resistance as a result from increased secretions, mucosal edema, bronchoconstriction, airway inflammation, or forign body aspiration (asthma, emphysema, chronic bronchitis, croup, acute epiglottis, aacute bronchitis)
Lung tissue involvement (interstitial pulmonary fibrotic diseases, aspiration, ARDS, cardiogenic pulmonary edema, drug-induced pulmonary edema)
Pulmonary vascular problems (pulmonary thomboembolism, pulmonary vascular damage)
Increased metabolic rates with pulmonary problems
Postoperative pulmonary complications
Dynamic hyperinflation (air trapping)
Acute hypercapnic respiratory failure (acute ventilatory failure)
A person can't achieve adequate ventilation to maintain a normal PaC02
Tachycardia and tachypnea are early detectors of
What are mild to moderate respiratory findings of hypoxemia?
Tachypnea, dyspnea, paleness
What are severe respiratory findings of hypoxemia?
Tachypnea, dyspnea, cyanosis
What are are mild to moderate respiratory findings of hypercapnia?
What are severe respiratory findings of hypercapnia?
Tachypnea (eentually bradypnea)
What are mild to moderate cardiovascular findings of hypoxemia?
Tachycardia, mild hypertension, peripheral vasoconstriction
What are the severe cardiovascular findings of hypoxemia?
Tachycardia (eventually bradycardia, arrhythmias)
hypertension (eventually hypotension)
What are mild to moderate cardiovascular findings of hypercapnia?
Tachycardia, hypertension, vasodilation
What are severe cardiovascular findings of hypercapnia?
Tachycardia, hypertension (eventually hypotension)
What are the mild to moderate neurological findings of hypoxemia?
Restlessness, disorientation, headaches, lethargy
What are the severe neurological findings of hypoxemia?
Somnolence, confusion, delirium, blurred vision, tunnel vision, loss of coordination, impaired judgement, slowed reaction time, manic depressive acitivity, loss of consciousness, coma
What are the mild to moderate neurological findings of hypercapnia?
Headaches, drowsiness, dizziness, confusion
What are the severe nuerological findings of hypercapnia?
Hallucinations, hypomania, convulsions, loss of consciousness (evntually coma)
What are other signs of hypercapnia?
Sweating, skin redness
What does severe hypercapnia eventually lead to if left untreated?
C02 narcosis, cerebral depression, coma, and death
PaC02 levels are elvated with hypoxemia unless the patient is recieving oxygen therapy during?
hypercapnic respiratory failure
What does untreated hypoxemia, hypercapnia, and acidosis lead to?
Cardiac dysrhythmias, v-fib, and/or cardiac arrest
What are 3 things needed to achieve a successful outcome in respiratory failure?
Supplemental oxygen therapy, maintain patent airway, continuous monitoring of oxygenation and ventilatory staus with pulse ox and ABG
A breathing pattern with apneas that last 10 to 30 seconds followed by gradual increase in the depth and rate of breaths
What is cheyne-Stroke respiration associated with?
Cerebral disorders, congestive heart failure, metabolic problems
Periods of apnea lasting 10 to 30 seconds followed by breathing at a uniform depth
What is biot respirations associated with?
Central nervous system disorders (meningitis) and increased intracranial pressure
What are the ventilatory indications of acute respiratory failure and the need for mechanical ventilatory support in adults?
pH <7.25; PaC02 >55 mmHg; Vd/Vt >0.6
What are the oxygenation indications of acute respiratory failure and the need for mechanical ventilatory support in adults?
Pa02 <70 (on 02 >=0.6); PA-a02 >450 (on 02); Pa02/PA02 <0.15; Pa02/Fi02 <200
Abdomen moves out during exhalation and moves in during inhalation while the chest wall moves out during inhalation and in during exhalation
What are the critical values that indicate a need for mechanical ventialtion?
MIP -20 to 0; MEP <40 cm H20; VC <10 to 15; Vt <5; f >35; FEV1 < 10 ml/kg; PEF 75 to 100 L/min
What helps quanify airway resistnace in asthma and COPD?
FEV1 and PEF
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