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RES 235 Adv. MV Final Exam Questions And Answers!!
When is VAP most likely to occur? - ANSWER early on- first 48 to 72 hours
How to decrease the incidence of VAP? - ANSWER -Clean techniques -handwashing and gloves -elevated HOB -oral hygiene -maintaining adequate cuff pressures -no lavaging during sx -HME changes when contaminated -do not break vent circuit -in-line sx cath -single pt items -avoid gastric lavage -remove gastric tubes asap -ambulation
What puts a pt at increased risk of developing VAP? - ANSWER -Alcoholism -diabetes -ABX treatment -nasogastric tubes -supine -nasal intubation surgery
-leukocytopenia -coma -immunosuppressed -malnutrition -hypotension -hypoxemia -bronchoscopy -concurrent steroid tx -overuse of sedative/paralytics -poor hand hygiene with ventilator care and airway care
Do you know what an analgesic does? - ANSWER lessens pain
examples of analgesics - ANSWER -Morphine -fentanyl -NSAIDs -opiods -codeine -oxycodone etc.
______ analgesics include epidurals medications and Propofol - ANSWER surgical
Do you know what a sedative does? - ANSWER Relaxes, promotes sleep, decreases agitation and reduces anxiety
examples of sedatives - ANSWER -Versed -Valium
Capnography: inspiration begins and CO2 levels quickly return back to baseline (zero) - ANSWER Phase 4
Effects of + Pressure on GI function - ANSWER · Gastric distention · Gastric mucosal ischemia · GI bleeds and ulcers · Nosocomial pneumonias
Effects of + Pressure on Kidneys - ANSWER · Kidneys respond to hemodynamic changes as a result of increased intrathoracic pressures · Stretch/baroreceptors in carotid arteries and aorta detect decreased blood flow, sends impulse to produce more ADH, kidneys produce less urine
Effects of + Pressure on ICPs and Cerebral Perfusion - ANSWER · Cerebral perfusion is proportional to CO and Mean Systemic BP · Acidosis causes cerebral vasodilation increasing cerebral blood flow and intracranial pressure · Central respiratory depression at very high levels of pCO · Poor cardiac output combined with severe hypoxemia decreases cerebral perfusion and leads to ischemia and brain death
Why do we care about pt.'s nutritional status? - ANSWER -muscle strength -organ function -surfactant production etc.
How do we look at renal function? - ANSWER -UOP -BUN -Creatinine
-body wall edema etc.
How do we look at neurological status? - ANSWER -Mental status -pupil response -corneal and gag reflex -ICP monitoring -Glascow Coma etc.
How do we look at cardiovascular status? - ANSWER · Hemodynamics
- SWAN -BP -CVP -arterial waveform size -heart tones (murmurs) -preload -afterload -stroke volume -ejection fraction -HR -ECG waveform and rhythm, etc.
How do we measure WOB - Compliance and RAW? - ANSWER -Plat -graphics -loops -scalars -PEFR -inspiratory and expiratory holds
In order to be successful, what is needed by pt before extubation? - ANSWER · Ability to protect aw - effective cough, gag · Airway patency - minimal edema, cuff leak · Adequate pulmonary hygiene · Stability of cardiovascular status · Strong spont. respiratory drive
What are the most important criteria for weaning? - ANSWER · Reversal of disease or condition that required MV · O2 less than 50% · Medically and hemodynamically stable · Spont. breathing
Low V/Q= - ANSWER shunt
With low V/Q (shunt), your ETCO2 readings will be:
Why? - ANSWER -higher than normal -because the perfusion is bringing plenty of CO2 to the alveolus faster than it can be exhaled due to the lessened ventilation so eventually an excess buildup leads to increased ETCO2 readings
- hypoventilation, many of our restrictive respiratory diseases, CNS depression, neuromuscular disorders
- higher than normal ETCO2 readings because of increased metabolism, so more waste or CO2 is produced
High V/Q = - ANSWER Deadspace
High V/Q has _____ than normal ETCO
Why? - ANSWER lower
-there is great ventilation removing the CO@ rapidly out of the alveolus faster than the perfusion or blood flow can bring it back into the alveolus.
- hyperventilation, pulmonary emboli, excessive positive pressure decreasing venous return, CPR, PPHN, or anything that restricts pulmonary blood flow
- Lower than normal ETCO2 readings because of decreased metabolism, so less waste or CO2 is produced
- Hypothermia, paralytics
If the waveform is not returning to baseline, the patient is: - ANSWER rebreathing CO
Shark fin looking waveform may indicate: - ANSWER RAW (obstruction)
If the plateau on waveform is not flat: - ANSWER esophageal intubation or leak -ETT could be too small
If there is a notch on the plateau : - ANSWER indicates vent-pt asynchrony or breaking through a paralytic
3 main modes for weaning - ANSWER 1.Spontaneous breathing trials (SBT) 2.SIMV 3.PSV
acceptable values for SRR - ANSWER 6-30 b/min
acceptable values for spont VT - ANSWER >5-8 mL/kg
acceptable value for RSBI - ANSWER <
acceptable values for minute ventilation - ANSWER <10 L/min
acceptable values for MIP - ANSWER <-20 to 30 mmHg
Continuous graphic display of exhaled CO2 levels as they change during breathing - ANSWER Capnography
Measures exhaled CO2 levels numerically without a waveform - ANSWER Capnometry
What types of capnographs are there and which do we use mostly in our ICUs? - ANSWER Infrared Spectroscopy & Chemical
- inline between ETT and circuit o Adds deadspace o Adds weight o Most accurate - ANSWER mainstream capnography
o Pulls out a bit of volume o Line gets condensation quickly and interferes with accuracy o Delay in graph since it pulls out CO2 and sends to monitor o Not ideal for rapidly breathing pts. or those with small Vts - ANSWER side stream capnography
HFOV stands for: - ANSWER High Frequency Oscillator Ventilation
mode of ventilation used for lung recruitment for low compliance diseases or conditions
mode of ventilation best for heterogeneous disease states - ANSWER HFOV
mode of ventilation used for lung rest or decruitment, air leaks and occasionally for secretion removal - ANSWER HFJV
HFJV stands for: - ANSWER High Frequency Jet Ventilation
mode of ventilation best used for homogenous disease states - ANSWER HFJV
Why do we look at Volume scalar? - ANSWER Leaks mostly
Decreases adverse effects of invasive intubation, CMV and cardiovascular effects of MV
Signs of NIV failure include: - ANSWER -no improvement or worsening of ABGS -increase WOB or FiO2 needs -pt. unable/unwilling to cooperate -delivery device deficits is most common reason for failure
-pt effort/trigger -difference in PIP and PLAT (Pta)
Why do we look at Flow scalar? - ANSWER -Vent-pt synchrony -missed triggers if flow is depleted but no breath is delivered -air trapping -time constants determination (length of time for flow to return to baseline) -PEFR for obstructions -to set the TLOW on APRV appropriately -help determine the type of mode -to help determine the appropriate inspiratory time for PC ventilation
mode of ventilation that may compromise cardiovascular status - ANSWER HFOV
only mode of ventilation with active exhalation (piston) - ANSWER HFOV
Parameters for HFOV: - ANSWER -MAP -Delta P -Hz -IT% -FiO
HFOV: MAP = - ANSWER oxygenation
HFOV: Delta P/Amplitude = - ANSWER ventilation
HFOV: Hz = - ANSWER can affect ventilation and VT
HFOV: increase ____ or ____ for poor oxygenation - ANSWER MAP; FiO
HFOV: Increase _____ for poor ventilation (chest wiggle troubleshooting) - ANSWER Delta P
HFOV: Lower ___ for poor ventilation - ANSWER Hz
Servo pressure indicates how hard the vent needs to work to deliver the settings in this mode of ventilation - ANSWER HFJV
Used for refractory hypoxemia with relatively good ventilation for spontaneously breathing pts - ANSWER APRV
Concept is using an Inverse I:E ratio to give more time for oxygenation and lung recruitment - ANSWER APRV
Parameters for APRV include: - ANSWER -FiO -PHigh -PLow -THigh -TLow
upper CPAP level for APRV - ANSWER PHigh
lower CPAP setting for APRV - ANSWER PLow
the inspiratory time phase for the P High - ANSWER T High
-Results from infection not incubating at the time of admission. - ANSWER Hospital-Acquired Pneumonia (HAP)
Depolarizing Paralytic Agents (short acting) - ANSWER Succinylcholine (Anectine) -used for RSI mostly
Nondepolarizing Paralytic Agents (Longer acting) - ANSWER -Pancuronium (Pavulon) -Vercuronium (Norcuron) -Atracurium (Tracrium) -Cisatracurium (Nimbex)
Sedatives: - ANSWER Benzodiazepines -Diazepam (Valium) -Midazolam (Versed) -Lorazepam (Ativan)
Neuroleptics (tx delirium) -Haloperidol
Analgesics - ANSWER - Morphine
- Fentanyl
- NSAIDs
- Opioids
- Codeine
- Oxycodone
- Surgical analgesics include epidural medications and Propofol
How often does stridor occur after extubation? - ANSWER 2-16% of patients
Which medication may give the patient anterograde amnesia? - ANSWER Diazepam (Valium)
Which type of acute respiratory failure is life-threatening if no rapid clinical improvement is noted after initiating NIV? - ANSWER Hypoxemia respiratory failure
Which predicts the unsuccessful use of NIV in the respiratory failure patient? A. low severity of illness B. pH </= 7. C. improvement of gas exchange within 30 min D. minimal air leaks - ANSWER B. pH </= 7.
Which is a common reason for NIV failure? A. mask related leaks B. uncooperative patient C. apnea D. all of the above - ANSWER D. all of the above
I:E ratio for HFOV - ANSWER fixed 1:2 ratio
How to manipulate ventilation with HFOV - ANSWER Delta P and Hz
HFJV, Jet Parameters - ANSWER -PIP -Rate -IT -FiO
length of time which P High is maintained - ANSWER T High
APRV parameter:
- adjusted to stop exhalation at 50-75% of PEFR
- used to control alveolar recruiting "actual" PEEP and tidal volume - ANSWER T Low
With restrictive lung disorder pts T low is adjusted to stop exhalation at ___________ of PEFR - ANSWER 50-75%
With obstructive lung disorder pts T low is adjusted to stop exhalation at ___________ of PEFR - ANSWER 25-50%
How to improve oxygenation in APRV: - ANSWER -increase FiO
- increase P high
- increase T high
- reduce sedation to encourage more spontaneous breathing
- add PS
How to improve ventilation in APRV - ANSWER - increase P high
- decrease T high
- reduce sedation to encourage more spontaneous breathing
- add PS
What does "drop and spread" for APRV mean? - ANSWER - decrease P high
Used to help gradually wean from APRV. Eventually the patient will wean to equivalent
to CPAP with PS - ANSWER Drop and Spread method
Paralytics are characterized into what: - ANSWER -Depolarizing (Short acting) -Non Depolarizing (Long acting)
CO2 in capnography is increased with: - ANSWER - fever
- sepsis
- severe burns
- hyperthyroidism
- seizures
- increased WOB
- shivering
CO2 in capnography is decreased in: - ANSWER - hypothermia
Clinical applications of capnography - ANSWER - anesthesia
- monitor effectiveness of MV
- monitor the severity pulmonary disease & response to therapies
- measure the volume of CO2 eliminated to assess metabolic rate & alveolar ventilation
- used during transport of an intubated pt
- confirm intubation (chemical)
- assess blood flow in CPR (assesses the quality of compressions & to detect ROSC)
- spontaneously breathing pt receiving conscious sedation
Vd/Vt formula - ANSWER (PaCO2 - PECO2) / PaCO
