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UNIT 4 - VENTILATOR USAGE

 

1. Discuss the advantages and disadvantages of pressure vs. volume ventilation= .

 

        &= nbsp;   VOLUME        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;        PRESSURE=

- guarantee Vt to assure adequate ventilation  &n= bsp;         - can control pressure to limit risks of barotrauma

- volume constant, pressure variable        &= nbsp;           &nbs= p;      - pressure constant, volume variable

        &= nbsp;     &n= bsp;            = ;            &n= bsp;            = ;                      =           - compensates for leaks

 

2. Name at least 5 things that should be checked on a vent before placing it o= n a pt.

 

        &= nbsp;   - = circuit properly assembled    &= nbsp;           - make sure settings are appropriate

        &= nbsp;   - check system for leaks           &nb= sp;          - check return volume

        &= nbsp;   - check alarms&nbs= p;            &= nbsp;           &nbs= p;           - humidifier ready

        &= nbsp;   -preuse check

3. Describe and give appropriate initial settings for the following.

 

        &= nbsp;   -FiO2- if in doubt, start at 1.00 with pulse ox., can wean qu= ickly, post-surgicals probably 40-70%

-Vt- start at 8-10 ml/kg IBW, get ABG’s to verif= y, note: we are seeing many people using smaller Vt= now, if there is evidence of ARDS or ALI will probably start at 6-7 ml/kg

        &= nbsp;   - Rate- usually 10-16, depends on mode and ABG’s

        &= nbsp;   - I:E ratio- usually 1:2, may depend on flow<= /o:p>

        &= nbsp;   - Pressure- set pressure limit according to pt.

-      =     if using pressure vent, set to get desired Vt

- Flow- usually 40-80 lpm

        &= nbsp;   - Trigger- easiest to trigger without self-triggering, pressure=3D 0.5-2 cmH2= O, flow 1-3 lpm

        &= nbsp;   - Sigh- usually set 1.5-2 x’s set Vt, 5-15 p= er hour

-PEEP- some people think 3 cmH2O necessary for physiolog= ic PEEP, we see low levels of PEEP used more now

        &= nbsp;   - Insp. pause or plateau- holds insp. in, improves oxygenation, improves med delivery, 0-0.5 sec.

 

4. Discuss the physiologic effects of mechanical ventilation on lungs.

 

        &= nbsp;   - = decreased WOB      &nbs= p;            &= nbsp;           - changes pt’s normal breathing pattern

        &= nbsp;   - some mechanical dilation            =       - gas is more evenly distributed t/o lungs

- increased oxygenation     &n= bsp;            = ;    - may cause increased V/Q mismatch, ventilation more even, though perfusion is still gravity dependent

        &= nbsp;   - increased PVR

        &= nbsp;   -keep plateau pressures less than 30 cm H2O

        &= nbsp;   -use PEEP level that will keep alveoli open

        &= nbsp;           &nbs= p;            &= nbsp; 

5. Discuss which parameters will effect MAP and how= they affect MAP.

     &= nbsp;      in= creased MAP=3D

        &= nbsp;           &nbs= p;   - increase rate&nb= sp;            =             &nb= sp;            =             &nb= sp;           - increase PEEP     =             &nb= sp;    

        &= nbsp;           &nbs= p;   - increase flow, if it increases PIP        &= nbsp;           &nbs= p;          - increase Vt if it increases PIP

        &= nbsp;           &nbs= p;   -increase Ti  = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp; - increase sigh

        &= nbsp;           &nbs= p;   - increase inspiratory pause            =             &nb= sp;            =     - decrease expiratory time

        &= nbsp;           &nbs= p;   -change to a mode with more mechanical breaths = ;    

 

 

6. Discuss the physiological effects of mechanical ventilation on the cardiovascular system.

 

     = ;       -d= ecreased venous return- depends on:

        &= nbsp;           &nbs= p;   a. magnitude of positive pressure

        &= nbsp;           &nbs= p;   b. intravascular blood volume

        &= nbsp;           &nbs= p;   c. strength of heart

        &= nbsp;   - decreased stroke volume- pump against intrathora= cic pressure

        &= nbsp;   - tachycardia

        &= nbsp;   - ideal ventilatory pattern- decreased Ti, increas= ed Te, low pressure

- someone with elastic lungs or high Raw will have less impingement= on intrathoracic pressure and may not see as much cardiac effects from ventilator

        &= nbsp;   -decreased coronary artery perfusion

        &= nbsp;   -increased PVR due to stretching of pulmonary vessels

        &= nbsp;  

        &= nbsp;   Possible beneficial effects of PPV on cardiac function:

        &= nbsp;   -If hypoxemia relieved, cardiac function improves

-increased mean airway pressure and intrathora= cic pressure can reduce preload to a failing left ventricle and actually improve function

        &= nbsp;   -left ventricular compliance may be affected and LV function may increase or decr= ease

 

7. Discuss the physiologic effects of mechanical ventilation on the kidneys.

 

        &= nbsp;   - increased ADH production, decreased urinary outp= ut

        &= nbsp;   - decreased blood flow to kidney, decreased urinary output

        &= nbsp;   - redistributes renal blood flow more to areas that are less effective at removing fluid

        &= nbsp;   - decreased PaO2 and increased PaCO2 will decreased renal blood flow

 

8. Discuss the effects of mechanical ventilation on a pt’s psyche.<= /o:p>

 

        &= nbsp;   -restraints  =             &nb= sp;     - not able to communicate   &n= bsp;            = ;   -sleep difficult

        &= nbsp;   - lack of control&= nbsp;          - inability to clear secretions  &n= bsp;            -anxiety about appearance and hygiene

        &= nbsp;   - lack of privacy&= nbsp;         - removal of family and friends  &n= bsp;       -depression

        &= nbsp;   - inability to eat=            - constantly uncomfortable   &= nbsp;           &nbs= p; -confusion

        &= nbsp;   - abstinence =             &nb= sp;   -anxiety about outcome

 

9.         = Cerebral perfusion pressure (CPP) determines cerebral blood flow.  CPP=3DMABP – ICP.=

PPV mostly affects ICP in patients who already have increased ICP.<= span style=3D'mso-spacerun:yes'>  Decreased venous return from head = will increase ICP.  Hyperventilatio= n in closed head injury is controversial.  Only use hyperventilation if ICP is being monitored and you can tell hyperventilation actually improves CPP.&nb= sp; Hyperventilation is generally only effective for 24-36 hours.

 

10.       Descr= ibe some general guidelines when making ventilator changes

        &= nbsp;   - try not to change too many parameters at once

        &= nbsp;   -identify as either ventilation or oxygenation problem

        &= nbsp;   -consider cardiovascular effects of change

 

 

11. State how to manipulate PaCO2 by making changes on the vent.

 

        &= nbsp;           &nbs= p;   a<= /span>. rate- increase rate = =3D decrease PaCO2

        &= nbsp;           &nbs= p;   b. Vt,PIP- increase Vt= =3D decrease PaCO2

        &= nbsp;           &nbs= p;   c. mode- decrease WOB, more control =3D decrease PaCO<= sub>2

        &= nbsp;           &nbs= p;   d. deadspace- increase Vds= =3D increase PaCO2 ( use only in A/C or control)

        &= nbsp;           &nbs= p;   e. manage pt’s on vent to get a normal PaCO= 2 for that particular pt.

 

12. State how to manipulate PaO2 by making changes on the vent.=

     &= nbsp;      - increase FiO2

        &= nbsp;   - PEEP- increase PEEP =3D increase PaO2

        &= nbsp;   - plateau pressure- increase pause =3D increase Pa= O2

        &= nbsp;   - increase mean airway pressure

-will probably see inc in PaO2 with any change that increases minute alveolar ventilation

 

13. State the proper ways to achieve a normal pH by making changes on the vent.=

 

        &= nbsp;   - identify whether metabolic or respiratory problem

        &= nbsp;   - fixing PaCO2 will eventually fix pH

 

14. List 6 complications of alkalosis.

 

     = ;       a<= /span>. decreased cardiac ou= tput        &= nbsp;           &nbs= p;            &= nbsp;             &= nbsp;   b. tetany

        &= nbsp;   c. hypokalemia/dysrhythmias           &nbs= p;            &= nbsp;           &nbs= p;             = d. seizures

 &nb= sp;          e. decreased cerebral blood flow/dizziness        &= nbsp;           &nbs= p;        f. decreased unloading of O2 at the tissues

 

15. State how often vent checks should be done.

 

        &= nbsp;   - best to do Q2-Q3

        &= nbsp;   - try to do right away on your shift

 

16. State five general purposes of vent checks.

 

        &= nbsp;   Purpose:

        &= nbsp;           &nbs= p;   a. pt assessment, make sure pt vent system is working = well

        &= nbsp;           &nbs= p;   b. vent parameters are accurate/match doctor’s o= rders

        &= nbsp;           &nbs= p;   c. vent is working properly

        &= nbsp;           &nbs= p;   d. any effects of vent changes that have been made

        &= nbsp;           &nbs= p;   e. have a floating record of the mechanical ventilatio= n

 

17. Name at least 8 items that should be checked when doing vent checks.

 

        &= nbsp;    Vt        &= nbsp;           &nbs= p;          humidification     = ;       leaks      &n= bsp;            = ;            &n= bsp;       VG setting

        &= nbsp;    Ti&= nbsp;           &nbs= p;            &= nbsp;      volumes      =             &nb= sp;   flow/pressure curves    = ;          rise time

        &= nbsp;    PEEP            &n= bsp;            = ; cuff pressure          &= nbsp;  deadspace        &= nbsp;           &nbs= p;          compliance<= o:p>

        &= nbsp;    FiO2            =             &nb= sp;   minute ventilation    &= nbsp; sensitivity     &n= bsp;            = ;             <= /span> resistance

        &= nbsp;    rate        &= nbsp;               &= nbsp;   alarms  &n= bsp;            = ;          MAP        &= nbsp;             &= nbsp;           &nbs= p;   PS level

        &= nbsp;    mode        &= nbsp;           &nbs= p;     I:E      &nbs= p;            &= nbsp;          end tidal CO2

        &= nbsp;   flow   =             &nb= sp;        &= nbsp;   pressures        &= nbsp;           &nbs= p; pause time     &nb= sp;                   &= nbsp;   water in tubing

 

18. Name at least 10 things that should be checked on a patient when doing vent checks.

 

1.      br= eath sounds        &= nbsp;           &nbs= p;           9. color

2.      ch= est excursion/symmetry        &= nbsp;    10. breathing rate

3.      ur= inary output        &= nbsp;           &nbs= p;          11. blood pressure

4.      pu= lse ox            =             &nb= sp;            =     12. heart rate

5.      ET CO2        &= nbsp;           &nbs= p;            &= nbsp;       13. tube placement

6.      pa= tient = dyspneic?        &= nbsp;           &nbs= p;     14. sensorium

7.      sy= nchrony with vent        &= nbsp;            15. accessory muscle usage

8.      he= modynamic monitoring        &= nbsp;    16. is tube secure?

 

 

 

 

19. Describe what should be checked on the humidifying system while doing ventilator checks.

 

        &= nbsp;   a. H2O level

        &= nbsp;   b. temperature- 33-34 C,  possibly 36-37o C in neonates, insp. side near pt.

        &= nbsp;   c. check change date

        &= nbsp;   d. drain H2O traps

        &= nbsp;   e. water in circuit

 

20. List 3 major kinds of pt. alarms on the vent.

 

     &= nbsp;      1. apnea / disconnected ( apnea, low PIP, low exp. Vt)

        &= nbsp;   2. power loss / gas supply alarm<= /p>

        &= nbsp;   3. pressure limit

 

21. List 6 other alarms or lights which may be present on a vent.

 

        &= nbsp;   a. low min. vol. =           c. high / low FiO2   = ;     e. inverse ratio alarm   g. l= ow battery

        &= nbsp;   b. high / low rate&nbs= p;        d. sensitivity / trigger  f. low V= t        &= nbsp;            h. heater

 

22. State the possible causes of a pressure limit alarm sounding.

 

    &nbs= p;        bucking<= span style=3D'font-size:12.0pt;mso-bidi-font-size:10.0pt'> the vent        &= nbsp;           mucus plugging     = ;     H2O in tubing   &= nbsp;         coughing

        &= nbsp;    secretions        &= nbsp;           &nbs= p;          biting tube     &n= bsp;            worsening disease

        &= nbsp;    bronchospasm        &= nbsp;           &nbs= p;   pneumothorax     &= nbsp;          process, decrease in compliance

        &= nbsp;   tube in mainstem bronchus     air trapping    

 

23. List 6 possible causes of low exhaled volumes on the vent.

 

        &= nbsp;   a<= /span>. air trapping        &= nbsp;           &nbs= p;            &= nbsp;    e. leak in circuit    &nbs= p;            &= nbsp;     i. self extubation

        &= nbsp;   b. low inhaled Vt &nbs= p;            &= nbsp;             &= nbsp;   f. pt. Disconnection    &n= bsp;           j. alarm set inappropriately

        &= nbsp;   c. bad cuff  = ;            &n= bsp;            = ;            &n= bsp;   g. leaky valve     &n= bsp;            = ;        k. breath stacking

        &= nbsp;   d. humidifier loose&nb= sp;            =             &nb= sp;    h. bronchopleural fistula   &nb= sp;     l. pressure limiting

 

 

24. Describe where to set alarms while doing vent checks.

 

        &= nbsp;   - set to protect and monitor pt.

        &= nbsp;   - check to make sure they are set, and set appropriately for that patient

 

 

25 & 26.Name four things that will affect patient airway pressure on a vol= ume ventilator.

 

     &n= bsp;      A. Resistance-

        &= nbsp;           &nbs= p;   1. et tube size

        &= nbsp;           &nbs= p;   2. airways diameter ( tumor, secretions, bronchospa= sm)

        &= nbsp;           &nbs= p;   3. flow

 

        &= nbsp;   B. lung compliance-

        &= nbsp;           &nbs= p;   1. lung compliance (fibrosis, ARDS, edema)

        &= nbsp;           &nbs= p;   2. size of lungs

 

        &= nbsp;   C. chest wall compliance-

        &= nbsp;           &nbs= p;   1. pleural fluid

        &= nbsp;           &nbs= p;   2. chest wall configuration

        &= nbsp;           &nbs= p;   3. intercostal muscle tone

        &= nbsp;           &nbs= p;   4. pt. position

        &= nbsp;           &nbs= p;   5. abdominal contents

        &= nbsp;           &nbs= p;   6. chest trauma

 

&nbs= p;           D. set tidal volume- increased tidal volume will usually increase pressure

 

27.  Calculate corrected Vt if tubing compliance is known.

 

        &= nbsp;   Vt corrected =3D Vt se= t - ( tubing compliance x PIP)

 

28. Calculate static compliance, dynamic compliance, and Raw.=

 

     &= nbsp;      C= stat =3D Vt / (plateau pressure – PEEP)

        &= nbsp;   - measures how much it takes to keep lung inflated, no air movement

 

        &= nbsp;   Cdyn =3D Vt / (peak pressu= re – PEEP)

        &= nbsp;   - measures when there is a gas flow and takes Raw = into account

 

        &= nbsp;   Raw =3D peak pressure - pause divided by flow(lpm) a= nd then multiply by 60

 

        &= nbsp;   - the greater the difference between peak and paus= e, the more likely a Raw  problem

        &= nbsp;   - the smaller the difference, the more likely a compliance problem

 

29. Airways resistance is portion of curve between peak and pause pressure.  Dynamic compliance is portion of c= urve between peak pressure and PEEP.  Static compliance is portion of curve between pause pressure and PEE= P.

 

 

30. State the importance of ventilator tubing changes.  Time between changes is getting extended.

 &nb= sp;          to avoid nosocomial infections due to warm, moist environment

 

31. State two things to consider whi= le changing the tubing on a ventilator.

        &= nbsp;   avoid contamination, maintain pt. ventilation

 

 

32. =       Best place to place neb in-line with ventilator circuit is between water trap and tubing on inspiratory side or half way down inspiratory tubing.<= /span>

 

33.       To te= st effectiveness of bronchodilator therapy through ventilator circuit:

 

        &= nbsp;           &nbs= p;   See if peak pressures decreased

        &= nbsp;           &nbs= p;   Has air trapping gone away?

        &= nbsp;           &nbs= p;   Have breath sounds improved?

        &= nbsp;           &nbs= p;   Has dynamic compliance improved?

        &= nbsp;           &nbs= p;   Do graphics look more normal?

 

9/09    

 

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