Based on the clinical presentation, the most likely diagnosis is pneumonia. Key findings supporting this include:
- History of smoking and alcohol use, which are risk factors
- Fever, chills, and chest pain on inspiration, which are common symptoms
- Rust-colored sputum, indicating presence of blood
- Tachypnea and inspiratory crackles on exam, localized to the right lower lobe
The immediate treatments that should be initiated are:
1. Supplemental oxygen via nasal cannula or mask to address his hypoxemia
2. IV fluids for hydration
3. Blood cultures to identify causative organism
4. Broad spectrum IV antibiotics to treat presumed community-acquired pneumonia
5. Chest
2. Assessment of the mechanically ventilated
patient
◦ Physical assessment
◦ Vital signs
◦ Clinical lab studies
◦ Nutritional status
◦ O2 status
Adequacy of arterial and tissue oxygen status
◦ Ventilation status
3. Critical thinking
◦ Decide what information is needed
◦ Monitor the appropriate values
◦ Collect the data needed
◦ Analyze the data
◦ Determine what changes are needed
◦ Implement changes
4. Chief Complaint
Primary symptoms of cardiopulmonary
disorders:
◦ Cough
◦ Sputum production
◦ Hemoptysis
◦ Shortness of breath (dyspnea)
◦ Chest pain
6. Subjective experience of breathing discomfort
◦ SOB - Cardinal symptom of cardiac disease
◦ Causes:
Obstructive and Restrictive conditions
acute hypoxia (high altitudes)
Exercise
heart failure (orthopnea)
kidney failure (uremia) due to acidosis
head injury (Biot’s)
pain.
7. Cardiac – Nonpleuritic pain
◦ Cardiac Ischemia
◦ Cardinal symptom of heart disease (Angina)
Pulmonary - Pleuritic pain
◦ Inspiratory, sharp, abrupt in onset
◦ Worsens with inspiration, cough, sneeze, hiccup, or
laughter
◦ Increases with pressure and movement
8. Temporary loss of consciousness
from reduced cerebral blood flow and oxygen
Causes:
• Pulmonary: embolism, bouts of coughing, hypoxia
• Vasovagal: most common type of syncope-Loss of
peripheral venous tone
• Orthostatic hypotension: Sudden drop in blood
pressure when a person stands up
• Elderly, vasodilators, dehydration
9. Vital signs (VS) are used to:
• Determine general status of the patient
• Establish a baseline
• Monitor response to therapy
• Observe for trends
• Determine the need for further evaluation or
intervention
10. Hematology
◦ The complete blood count (CBC)
◦ Tests of the blood clotting ability of the
patient’s blood
Blood Chemistry Tests
◦ Sodium
◦ Potassium
◦ Chloride
◦ Bicarb
BUN and Creatinine
11. Adequate nutrition key for healing
Nutritional status has major influence on
patient outcomes
◦ Provides energy for breathing and movement
Food quality and quantity affect oxygen
needs and CO2 production
Nutrients influence lung immune function
12. Inspection findings:
◦ Cachectic patients are bony with depressed
intercostal spaces
◦ Accessory muscles are often readily visible
◦ Poor cough secondary to muscle weakness
◦ Viscous secretions may suggest dehydration
13. Auscultation findings:
◦ Basilar coarse or fine crackles may indicate fluid
overload or loss of blood protein
◦ Wheezing secondary to food intolerance/allergy
◦ Fine late inspiratory crackles may indicate diminished
surfactant secondary to malnutrition
◦ S3 may indicate fluid overload and CHF
◦ S4 may indicate severe anemia
14. Neurologic dysfunction is difficult to
recognize in sedated patient
Obtain history, from family if not from patient
Neurologic examination
◦ Mental status
◦ Pupillary response and eye movement
◦ Corneal and gag reflex
◦ Respiratory rate and pattern
◦ ICP monitoring (10 to 15 mm Hg normal)
◦ Glasgow Coma Scale
15. Kidney functions
◦ Filtering and excretion of wastes
◦ Regulates fluid and electrolyte composition
Renal failure is noted by
◦ BUN increases of 10 to 15 mg/dl/day
◦ Creatinine increases of 1 to 2.5 mg/dl/day
◦ Urine volume reflects renal perfusion
Oliguria <400 ml/day in average-sized adult
Anuria occurs with <50 ml/day
18. P(A a)O2
◦ Healthy patient
21% O2, gradient is 5 to 15 mm Hg
100% O2, gradient is < 65mm Hg
◦ Abnormal increase associated with gas exchange problems
PaO2/FIO2 ratio (P/F ratio)
◦ Normal P/F ratio is 400 to 500.
◦ In Acute Lung Injury - ALI, this falls below 300.
◦ In Acute Respiratory Distress Syndrome - ARDS, will be <
200.
◦ Most reliable index of gas exchange if FIO2 > 0.50 and
PaO2 < 100 mm Hg
19. Pulse oximetry (“fifth vital sign”)
◦ Provides noninvasive measurement of SaO2,
referred to as SpO2
◦ Monitors only oxygen, not ventilation
◦ Significant limitations
20. All of the following are true about pulse
oximetry monitoring, except:
A. Provides an SpO2 reading
B. Provides invasive measurement of SaO2
C. Monitors only oxygen, not ventilation
D. Significant limitations
21. All of the following values affect pulse
oximetry, except:
A. Nail polish
B. Deeply pigmented skin
C. Anemia
D. CO2 buildup
22. Which of the following PaO2/FIO2 ratio
identifies a patient with ARDS?
A. 500-600
B. 300-500
C. >200
D. <200
23. Routine monitoring includes
PaCO2, which defines adequacy of ventilation
VT, f, and VE
Low VT and high f often indicate distress
VD/VT
Normal 0.20 to 0.40
Higher ratio indicates more wasted ventilation
ICU common to be > 0.60
>0.60, patient is unlikely to sustain spontaneous
ventilation
24. End tidal (Exhaled) CO2 monitoring
◦ Normal capnogram (less than 5 mmHg < PaCO2)
◦ 10 to 20 mmHg difference can be used to spot
trends
◦ > 20 mmHg difference indicates significant
deadspace
25.
26.
27.
28.
29.
30.
31. A patient who had abdominal surgery 4 days
ago has the following ABG pH – 7.48 mmHg,
PaCO2 – 28 mmHg, PaO2 – 95 mmHg, SaO2 –
98%, HCO3 – 21 mEq/L.
What is this patient’s acid-base status?
What is this patient’s oxygenation status?
The patient’s current hemoglobin content is 6
gm%
Does this change the patient’s acid-base
balance and/or oxygen status? Explain.
32. You are the evening shift respiratory therapist at your hospital
and have been summoned to the emergency department. Lisa
Camps, a 34-year-old woman, has just arrived in the emergency
department after a motor vehicle accident. She is on a non-
rebreathing mask at a flow rate of 12 L/min. The emergency
department physician wants your assistance in assessing and
managing Ms. Camps. Your assessment reveled the following
about Ms. Camp’s cardiopulmonary status?
• Color – dusky
• Pupillary reaction – sluggish
• Respiratory rate and pattern – 28/bpm and labored
• Level of consciousness – semiconscious and combative
• Pulse and blood pressure – 130/min, 130/90
• General appearance – Anxious, with bleeding from head laceration
• Chest auscultation – bilateral breath sounds diminished in the bases
• ECG – sinus tachycardia with a rate of 130/min
• ABG – pH 7.30, PCO2 50 torr, PO2 69 torr, HCO3 -25mEg/L
33. Which of the following would you recommend
at this time?
A. Placed patient on a CPAP mask of 5cmH2O
and 50% O2
B. Intubate and institute mechanical
ventilation.
C. Administer a bronchodilating agent via a
SVN, followed by postural drainage and
percussion.
D. Administer O2 via a 30% venturi mask.
34. The patient is combative and disoriented. To
facilitate intubation, which of the following
would you recommend?
A. Use restraints to immobilize the patient
B. Insert an oropharyngeal airway
C. Sedate and administer 2mg of
succinylcholine
D. Administer a bolus of lidocaine
E. Perform blind nasal intubation
35. The patient is 5ft 2in tall and weighs 50kg (110
lb). What ventilator settings would you
recommend?
A. Control mode, RR 10, Vt 750 ml, FIO2 0.50
B. AC, RR 10, Vt 500 ml, FIO2 1.0
C. SIMV, RR 6, Vt 700 ml, FIO2 7.0
D. SIMV, RR 10, Vt 600 ml, FIO2 4.0
E. AC, RR 10, Vt 750 ml, FIO2 0.50
F. SIMV, RR 2, Vt 850 ml, FIO2 1.0
36. ABG thirty minutes later reveal: pH 7.44,
PaCO2 36 torr, PaO2 189 torr, HCO3 -25
mEg/L. What will you recommend at this time?
A. Maintain current settings and monitor
closely
B. Titrate O2 percentage to maintain an SpO2
of more than 93%
C. Decrease Vt by 100 ml
D. Add PEEP of 5 cm H20
E. Decrease FiO2 to 0.50
37. After suctioning the ETT, the patient continues
to cough repeatedly, setting off the high-
pressure alarm. Which of the following would
you do at this time?
A. Increase the ventilator rate
B. Decrease the Fio2
C. Instill lidocaine into the ETT
D. Increase the high-pressure limit
E. Decrease the Vt
38. Twenty-four hour later, you are performing
ventilator checks on Ms. Camp’s ventilator
when the high-pressure alarm begins to sound
with each breath. Ms. Camp is in respiratory
distress with a respiratory rate of 32/bpm.
What will you evaluate at this time?
39. Ms. Camp continued…
Ventilator function – functioning normally with appropriately set parameters
Sputum color – clear
Temperature 37°C
MIP -60 cmH2O
No obstruction because the suction catheter is inserted and advanced into the
ETT.
Breath sounds absent on the right
Gag reflex intact
Bowel Sound normal
Papillary reaction normal
Hyperresonant sound over right upper
Increased resistance with difficulty to manually ventilate
Asymmetrical chest movement, with left lung expanding more than the right lung
Heart rate 130/min
Trachea deviated to the left of midline
40. Which of the following would you recommend
at this time?
A. Increase the high-pressure limit
B. Increase the high Vt
C. Decrease the ventilator rate
D. Insert needle into the second intercostals
space and then place a chest tube in the
right lung
E. Place a chest tube in the sixth intercostal
space
41. One week later, Ms. Camp remains on the ventilator on
AC with a Vt of 550 ml and an FiO2 of 0.35. On these
settings her ABG results are pH 7.42, PCO2 41 torr,
PaO2 90 torr, HCO3 24mEq/L. She has normal results
on her chest x-ray and her ICP in 5 mmHg, Temp 37°C,
MIP -31 cmH2O, RR 14/bpm, spontaneous Vt 350.
Which of the following would you recommend to
evaluate the patient readiness to wean?
A. Temp. – 37
B. MIP – 31
C. Spontaneous RR 14/bpm
D. Spontaneous Vt 350
42. Which of the following would you recommend
at this time?
A. Maintain present settings
B. Place on flow-by and 50% O2
C. Place on SIMV, RR 10/bpm, VT 600, FIO2
0.40,PS 10 cmH2O
D. Place on SIMV, RR 4/bpm, VT 600, FIO2
0.40,PS 10 cmH2O
E. Extubate and place on 40% aerosol mask
43. One hour later, ABG results are pH 7.38, PaCO2 38
torr, PaO2 87 torr, HCO3 -25mEq/L, SaO2 97%, RR
16/bpm and spontaneous Vt 375ml. Which of the
following would you recommend at this time?
A. Decrease the Vt by 100 ml
B. Maintain current settings and monitor closely
C. Increase the PS to 15 cm H2O
D. Decrease the RR by 2/bpm
E. Place on flow-by and PS of 5 cmH2O
44. The next day Ms. Camp is resting comfortably, with a
pulse oximeter reading of 98% and a spontaneous Vt of
400 ml. SIMV rate is 2/bpm, with a respiratory rate of
14/bpm and FiO2 of 0.30. Which of the following
would you recommend at this time?
A. Increase SIMV rate to 8/bpm
B. Place on flow-by ay 30% O2 and PS 8 cmH2O
C. Extubate and place on 24% air entrainment mask
D. Obtain ABG before making any ventilator changes
E. End of Case Study
45. Determining position of tubes and catheters
◦ ETT position (3 – 5 cm from carina)
◦ Chest tubes
◦ CVP and Swan Ganz
Observing the progression of lung disease
◦ Infiltrates and consolidations
Pneumonia
Atelectasis
Pulmonary edema
Pneumothorax and Pleural Effusions
46.
47.
48.
49.
50.
51.
52. A respiratory therapist working in the emergency
department encounters a 28 year-old female with
Kussmaul breathing. Her room air ABG values are
as follows: pH – 7.06 mmHg, PaCO2 – 12 mmHg,
PaO2 – 106 mmHg, SaO2 – 97%, HCO3 – 5 mEq/L.
What acid-base imbalance is present?
What oxygen therapy is appropriate at this time?
What is the most likely cause of this patient’s
condition?
60. A 55 year-old man arrives at the clinic with the
complaint of chills, fever and chest pain on
inspiration. He is coughing up rusty-colored
sputum. He admits to a history of heavy
smoking and regular use of alcoholic
beverages. Physical examination reveals a heart
rate of 125, respiratory rate of 30 and a
temperature of 104º F. He has inspiratory
crackles in the right lower lobe. Blood gases
reveal a pH of 7.34, PaCo2 of 50 and PaO2 of
50
61. What is the most likely diagnosis? Support your
answer based on the clinical signs and
symptoms.
What immediate treatment should you initiate?
Give five reasons why the patient is at risk of
dying from his condition.
62. What they measure
◦ CVP – fluid balance
◦ PAP – right ventricular function. Vascular resistance
in the lung (afterload)
◦ PCWP – Left ventricular function. Vascular
resistance in the systemic circulation
◦ Qt – the total amount of blood pumped by the heart
in in minute
63. MAP (PAW) = pressure in thoracic cage
Lungs & heart in thoracic cage
◦ CVP increased during PPV breath
◦ PAP increased during PPV breath
◦ PCWP increased during PPV breath
64. Constant pressure exerted in chest
◦ Measure hemodynamics while on PEEP
Patient will deteriorate when patient is discontinued
Physiologic PEEP
◦ ( 0-9 cmH2O )
Therapeutic PEEP
◦ ( ≥ 9 cmH2O )
65. A 70 year-old man’s chief complaint is
dyspnea on exertion. He has a smoking history
of two packs per day for the past 50 years. He
has a barrel-shaped chest and decreased
breath sounds. His chest radiograph shows
hyperinflation, especially in the apices;
flattened diaphragms; and an enlarged heart.
He admits to a morning cough with significant
sputum production.
66. What is the most likely diagnosis?
Calculate the patient’s “pack-years”
What factor should you focus on to help the
patient control his condition?
67. Air trapping during mechanical ventilation
◦ High minute volume
◦ Obstruction (increased exhalation times)
◦ Inspiratory times too long
◦ Irregular ventilatory pattern
◦ Asynchronous patient – ventilator interaction
68. Eliminate Raw
◦ Bronchodilation, suction, mechanical
Ensure patient – ventilator synchronicity
◦ PSV, sedation
Decrease I time
◦ Increase peak flow rate
Use extrinsic PEEP to splint airways
69. Vital Capacity
◦ N = 65-75 ml/Kg
◦ Ventilate below 15 ml/Kg
Rapid-Shallow breathing index
◦ Spontaneous Rate/Vt
◦ < 105 is predictive of successful weaning
MIP
◦ Normal = - 80 - -120 cmH20
◦ Acceptable = - 20 to 30 cmH2O for weaning
70. Respiratory infections
Increased work of breathing imposed
Operational hazards
◦ Power loss
◦ Circuit disconnect
◦ Expiration valve failure
71. Stress
◦ Anxiety
Loss of control, drugs, pain
◦ Combativeness
Lack of sleep, unfamiliar with environment
Fear
◦ Psychosis
Sleep deprivation, drugs, illness
72. Allow appropriate sleep
Introduce yourself, explain procedures
Allow normal stimuli
Minimize sedative drugs
Control pain
Antipsychotic medication
Appropriate communication around the
patient
73. Metabolic acidosis
◦ Stimulates an increase in ventilation
◦ Increased work of breathing
Metabolic alkalosis
◦ Stimulates a decrease in ventilation
◦ Weaning
74. Patients should be repositioned often
Take into account increased ICP patients
Unilateral lung disease
◦ Bad lung up, good lung down
◦ Will increase perfusion to well ventilated areas
ARDS Patients
◦ Will oxygenate better in the prone position
75. A patient is intubated and is on the ventilator
following a head injury. On the third day
following his craniotomy, he develops a fever.
During routine suctioning the RT notices his
secretions are thick and yellow. Breath sounds
are decreased in the left lower lobe.
76. What is the role of the artificial airway in the
development of pneumonia?
What test would you recommend at this time
to help confirm a diagnosis? Give at least two
tests.
85. PIP vs PplatPIP vs Pplat
NormalNormal High RawHigh Raw
High FlowHigh Flow Low CLow CLL
Time (sec)Time (sec)
PIPPIP
PPplatplat
PIPPIP
PIPPIP PIPPIP
PPplatplat
PPplatplat
PPplatplat
PPawaw
(cm H(cm H22O)O)
86. Volume control
◦ Square or rectangular waveform
Pressure control
◦ Decelerating ramp or waveform
Mimics a more natural breath
Volume control where you can choose your
waveform
◦ If you have a choice between Square or
decelerating, choose Decelerating. This will allow
for better distribution of ventilation
87.
88.
89.
90. You will be able to see if the sensitivity is
appropriately set for your patient
91. You can also see if the sensitivity is
inappropriately set for your patient
106. A mathematics instructor with a history of CHF is
admitted with a complaint of pain on inspiration.
Her respirations are rapid and shallow and her
heart rate is 104. The pulse oximeter shows a
saturation of 93% on room air. Breath sounds are
very decreased on the right side, with crackles in
the left base. Chest wall movement is markedly
less on the right. The chest radiograph shows
opacification of the right lung, with shift of
mediastinal structures to the left. Diagnostic
percussion reveals a dull note on the right.
107. What do you think is wrong with this patient’s right
lung? Support your conclusion with at least five (5)
pieces of information from the case.
◦ 1.
◦ 2.
◦ 3.
◦ 4.
◦ 5.
What would you recommend as the respiratory
therapist?
How could this disorder be resolved?
108. Volume
◦ Used to limit volume and pressure damage
◦ Normal lungs – 8 to 12 ml/Kg
◦ COPD – 8 to 10 ml/Kg
Limit volume, prolong expiratory time
◦ ARDS – 6 to 8 ml/Kg
◦ Neuromuscular – 12 to 15 ml/Kg
109. Rate
◦ Normal lungs – 8 to 12
◦ COPD – 8 to 12
◦ ARDS – may use up to 20 to normalize VE with
small Vt
◦ Neuromuscular – 10 to 14
After Vt is calculated use rate to adjust VE for desired
PaCO2
110. Adjust to desired PaO2/SaO2
◦ Most intrapulmonic shunting will not require more
than .40
◦ If significant shunting or deadspace occurs
Use PEEP for FIO2 > .60
Keep SaO2 above 90% or PaO2 around 60 torr
Increase inspiratory time or use inverse IE ratio
ventilation
111. A mechanical ventilator is set up to provide volume assist/control
ventilation to a postoperative patient.
What parameters does the respiratory therapist need to set?
During ventilation the patient’s peak inspiratory pressure
reaches approximately 28 cmH2O. What should the respiratory
therapist set as the maximum safety pressure?
What is the purpose of the maximum safety pressure?
While assessing the patient and checking the ventilator, the
respiratory therapist notices that although a volume of 500 mL
has been set, the patient exhales only 400 mL and the maximum
safety pressure is reached on each breath.
What is the most likely causes of the low volume return? Explain
your answer.
If the maximum safety pressure was not reached on each breath
and the exhaled volume was 100 mL less than the set volume,
what would be the possible causes?
112. Uses
◦ For restrictive lung disease (ARDS)
Hypo-inflation causes atelectasis (shunt)
FRC decreases
Use therapeutic levels (5 – 20)
◦ For normal lungs and obstruction
Splints airways
Exhalation more effective
Use physiologic levels (3 – 5)
Prevents auto - PEEP
113. Uses Continued
To decrease lung fluid (pulmonary edema)
◦ Increase alveolar pressure extends alveoli and
pushes out fluid from the interstitial space
◦ Increase in compliance from decreased lung water
eases the WOB of the patient
114. Use optimal PEEP studies
◦ Compliance study
◦ C(a-v)O2
◦ Qs/Qt
◦ Deadspace
◦ Direct measurement of Qt
◦ Use the highest PEEP level indicated
115. Optimum PEEP
◦ Keeps PaO2 > 60 torr with < .40 FIO2
◦ Increases lung static compliance
◦ Little impact on venous return
◦ Shunt is decreased
◦ FRC is increased
117. Minute ventilation
◦ Tidal volume
◦ Expiratory time (I:E and rate)
Lung function
◦ Resistance
◦ Compliance
Increase Pplat, Increase work-of-breathing,
hemodynamic effects, pneumothorax, difficulty
triggering
Correct by reducing minute ventilation (permissive
hypercapnia) and treating lung function.
118. Increase PEEP until there are no missed
trigger efforts
Increase PEEP until Pplat and PIP increase
PEEP to counterbalance auto-PEEP is only
effective in the context of flow limitation;
e.g., COPD versus asthma
119. A 35 year-old male with a history of Asthma is admitted to the ICU from
the emergency department. The patient is alert and oriented but
extremely anxious. He is sitting up and learning on the bedside tray
table. Physical examination reveals the following; pulse – 142 beats/min,
BP – 178/86 mmHg, Temp – 37.9° C, respirations – 33 breaths/min and
labored. Chest auscultation reveals significantly decreased breath
sounds throughout with slight wheezing on exhalation. ABG results on
40% air entrainment mask are as follows pH – 7.33 mmHg, PaCO2 – 44
mmHg, PaO2 48 mmHg, SaO2 – 79%, HCO3 – 22 mEq/L, Hb – 14.8 g/dL.
The peak expiratory flow meter is 70 L/min after three consecutive
bronchodilator treatments.
What is the cause of the patient’s tachycardia?
Using the four oxygenation indicators, explain the oxygen status of this
patient (assume PB is 760 mmHg).
Although this patient’s PaCO2 in within normal limits, why is it
significant in this case?
What respiratory care treatment should be suggested for this patient?
120. Improve gas exchange
Reduce VILI by reducing tension at
boundaries of aerated and non-aerated lung
units
Reduce VILI by reducing cyclic opening and
closing of lung units
Lung recruitment occurs at high volume and
pressures
Maintenance of recruitment requires PEEP
121. Methods
◦ Sustained high pressure inflation 30-40 secs at 35
to 40 cm H2O
◦ Stepwise increase in PEEP with decrease in tidal
volume over 2 minutes.
◦ CPAP of 30-40 cm H2O of 30-40 secs
◦ Increasing PIP by 10 cm up to 60 cm (30 s)
◦ PIP of 50 cm for 2 min
122. Sighs
PEEP
Recruitment maneuvers
Prone positioning
Spontaneous breathing
High frequency ventilation
123. Gas exchange – SpO2, PaO2, PaCO2
Pressure volume curve
Pressure time scalar
CT scan
124. ARDS = Lung aeration inhomogeneity
Low VT contributes to derecruitment
Recruitment is possible - more likely in
collapse vs. consolidation
Not all alveoli are recruitable at safe
pressures
Lung units are held open at much lower
pressure than is required to open them
The open lung is ventilated even during
expiration
Effect varies with type of ARDS
Greatest effect at low PEEP
125. A tall, young male respiratory care instructor, is
admitted with a complaint of pain on inspiration.
His respirations are rapid and shallow and his
heart rate is 104. The pulse oximeter shows a
saturation of 93% on room air. Breath sounds are
very decreased on the right side and clear in the
left base. Chest wall movement is markedly less
on the right. The chest radiograph shows a dark
area without lung markings on the right side with
a shift of mediastinal structures to the left.
Diagnostic percussion reveals increased
resonance on the right side.
126. What do you think is wrong with this patient’s
right lung? Support your conclusion with at least
five (5) pieces of information from the case.
◦ 1.
◦ 2.
◦ 3.
◦ 4.
◦ 5.
What would you recommend as the respiratory
therapist?
How could this disorder be resolved?
128. Closed head injury
◦ Increase Vt and rate to maintain PaCO2
Decrease to 25 – 30 torr
◦ Causes cerebral vasoconstriction
Decreased blood flow to injured site
Decreased swelling and bleeding
129. COPD
Ventilate to maintain baseline PaCO2/pH
◦ I:E ratio 1:3 or more
◦ Over distended lungs
◦ Obstruction causing decreased flows
Limit air trapping
Prevent auto PEEP
130. Preventing Intubation
◦ Heliox (60% - 80% helium with oxygen
◦ Continuous aerosol bronchodilator
◦ Noninvasive positive pressure ventilation
Invasive ventilation
◦ Oral vs. nasal intubation
◦ Ventilator settings
◦ Management of air trapping
◦ Delivery of inhaled bronchodilators
◦ Discontinuation of ventilatory support
131. ARDS
◦ Watch Peak and plateau pressures
◦ Watch for oxygen toxicity
Use PEEP when FIO2 needed > .60
Maintain SaO2 around 90%
◦ Increase rate with small Vt to keep PaCO2/pH
normal or permissive hypercapnea
◦ Use inverse I:E pressure control (IRPCV)
Increased oxygenation
Limit peak pressure
132. Normal lungs
Patients seem to “feel better” with larger Vt
Normal rate
Usually low FIO2
Protect against lung infection
Monitor for changes in Raw & compliance
134. Ms. Nelson is a 47 year-old woman who was
found unconscious on the floor of the apartment
by a relative. Empty bottles of diazepam (Valium),
effxor (antidepressant), and beer cans were
nearby. The relative dialed 911, and the patient
was transported to a local emergency room.
During transportation, the patient had an
adequate pulse rate but required ventilatory
assistance with a bag-valve mask on oxygen. An
ABG was obtained immediately, and a drug
screen was ordered in the emergency room.
135. What complications are likely to occur in this
patient?
What information should the attending
physician attempt to get from the relative or
paramedics?
Is this patient most likely to be experiencing
ventilatory or oxygenation failure?
Should the patient be intubated? If so, why?
What treatment should be provided?
136. Ms. Nelson continued…
Physical Examination
General. An unconscious, slightly obese female with an 8.0-mm
endotracheal tube in place being ventilated with a hand resuscitator;
Ewald tube in left nostril; gastric lavage fluid containing a large
number of pill fragments; strong smell of alcohol; patient
approximately 5 foot, 8 inches and 155 pounds.
Vital Signs. Pulse 124/minute, respiratory rate 12 to 16/minute with
bag-valve mask, body temperature 35.3°C (95.6°F), blood pressure
120/75 mm Hg
HEENT. No signs of trauma; pupils dilated with sluggish response to
light.
Heart. Normal heart sounds with no murmurs.
Lungs. Breath sounds clear except in right lower lobe, where
inspiratory crackles are heard.
Abdomen. Soft, obese, with no organomegaly or tenderness; bowel
sounds present, but hypoactive.
Extremities. Warm to palpation with no edema, clubbing, or cyanosis
Initial ABG Findings. (while patient is being ventilated with an FiO2
of 1.0 via a bag-valve mask prior to intubation). pH 7.28, PaCO2 54
mm Hg, PaO2 135 mm Hg, Sao2 99%, HCO3 = 26 mEq/liter
137. Ms. Nelson continued…
What accounts for the hypothermia?
What accounts for the dilated and sluggishly
reactive pupils?
What could account for the crackles heard in
the right lower lobe?
How would you interpret the ABG findings?
What is the significance of the pill fragments
found in the contents of the stomach? Why
was the charcoal given?
138. Ms. Nelson continued…
Ms. N is transferred from the emergency room to
the intensive care unit (ICU). While in the ICU, she
is placed on continuous mechanical ventilation
with a volume ventilator, and cardiac monitoring
is continued.
What laboratory and diagnostic tests would you
suggest at this time?
What ventilator settings would you recommend?
Specifically suggest the mode of ventilation, tidal
volume, rate, FiO2, and PEEP level.
139. Ms. Nelson cont…
The ventilator is set to deliver a tidal volume of 600 mL at
a rate of 12 per minute with an FiO2 of 0.45 in the
assist/control mode. Twenty minutes after initiation of
mechanical ventilation, an arterial blood sample is drawn
and reveals the following: pH 7.51, PaCO2 32 mm Hg,
PaO2 88 mm Hg, and HCO3 = 25 mEq. The chest x-ray
shows patchy infiltrates in the right lower lobe, which is
consistent with aspiration pneumonia. The
electrocardiogram monitor reveals a sinus rate of 115 to
120 per minute. Breath sounds are clear in all areas except
the right lower lobe.
A drug screen indicates that the patient had also taken
acetaminophen. Her blood alcohol level is 0.155, and the
presence of antidepressant is confirmed via urinalysis.
140. How would you interpret the ABG results?
What changes in the ventilator settings would
you suggest based on the ABG results?
What is the treatment for the acetaminophen
overdose?
What pulmonary complication is associated
with aspiration pneumonia?
141. Indications
◦ Peak and plateau pressure increase
◦ Decreased static compliance
◦ Inability to ventilate with pressures under 30 – 50
cmH2O
◦ Decreased FRC due to atelectasis
◦ Inability to oxygenate with conventional ventilation
142. What is does
◦ Delivers breath with a true decelerating waveform
Uses less force to deliver the same amount of volume
◦ Increases critical opening time
◦ Increases distribution of ventilation
◦ Increases oxygen diffusion into the blood
◦ Increases MAP (Paw)
143. Technique
◦ Choose PIP around ¾ of what is being delivered with
◦ Adjust I time to 1.5:1 to 3:1 ratio
◦ Decrease PEEP level to ½ of volume ventilation PEEP
level
◦ Adjust PIP to deliver the desired Vt
144. Increased distribution of ventilation
◦ Increased diffusion area (decreased shunt)
Increased critical opening time
◦ Enhanced spread of volume
Time constants
◦ Independent areas of alveoli/lobules that have
decreased compliance
146. Facilitated diffusion
◦ Gas molecules are driven during inspiration
◦ Follow a flow down the center of airways
◦ Expired gas (CO2) is pushed along the sides of the
airways
◦ Conventional ventilator breaths, CPAP or PEEP are
used to keep lung units open
147. Indications
◦ Ventilation at lower peak pressures
◦ Ventilation for patients with ARDS or
Bronchopleural Fistula
◦ Treating Pulmonary Interstitial Emphysema (
Pulmonary air leak problems)
148. Primary Controls
◦ Frequency (OXYGENATION)
Expressed in Hertz (Hz)
1Hz = 60 breaths per minute
◦ Driving pressure (VENTILATION)
Used in HFJV
Volume
◦ Amplitude (VENTILATION)
Used in HFOV
Volume
149. Types
◦ HFPPV
Rates 60 – 100/min (in Hertz)
Vt close to anatomical deadspace
◦ HFJV
Rates 100 – 600/min (in Hertz)
Vt close to anatomical deadspace
Needs special ETT with jet port
May damage airway mucosa
150. HFO
◦ Rates up to 900/min
◦ Vibration of gas molecule
◦ Kinetic movement of gas molecules
Moving air – base speakers
151. Uses
◦ Neonates with PPHN
◦ Congenital heart defects
◦ Barotrauma
◦ During bronchoscopy
◦ Investigational in limiting high pressures in adult
with ARDS
152. A Pressure Control mode with mandatory breaths
utilizing 2 pressure levels
A modified form of CPAP, in which the patient is able
to breathe spontaneously unrestricted at both levels
and if desired with the addition of Pressure
Support.
153. Goals:
To provide the lung protective ventilation by
delivering VT
Re-establishing FRC through recruitment and
maintained by creating intrinsic PEEP (PEEPi).
154. Benefits
Patients are able to breathe spontaneously throughout
the ventilatory cycle
Reduction in intrapulmonary shunting and dead space
ventilation is associated with spontaneous breathing
Venous return and cardiac performance can be
improved
Preserved diaphragmatic activity may recruit
consolidated lung areas over time and thus improve
oxygenation.
Neuromuscular blockade should be avoided: the
patient should be allowed to breath spontaneously
155. Terminology
Phigh (PEEP high)
◦ P High is similar to MAP and thus affects oxygenation
Plow (PEEP low)
◦ Always set at zero to account for the auto PEEP that
will occur
Thigh (Time high)
◦ From your TCT. The amount of time you will be
held at the Phigh
Tlow (Time low)
◦ The time to release CO2
160. WEANING:
1. The FiO2 should be weaned first
2. Reducing P High, by 2cmH20 increments until the P
High is below 20 cmH2O
3. Increasing T High to change vent set rate by 5
releases/minute until the patient is essentially on CPAP
with very few releases
4. Patients should be increasing their spontaneous rate
to compensate
5. Add Pressure Support with caution.
Add Pressure Support to P-High to decrease WOB
while avoiding overdistention,
P-High + PS < 30cmH2O
161. Introduced in 1994
You set patient’s height
ASV assumes that adequate minute
ventilation is 10L/min of IBW in Kg
RR and Vt are then automatically determined
based on the patient’s lung compliance
162. Used for patients with severe refractory
hypoxia
Monitored by measuring PAP
Improves pulmonary blood flow
◦ Improved V/Q
◦ Decreased shunt-deadspace
◦ Improved PaO2
163. Used for ARDS
Persistent pulmonary hypertension in
neonates
Congenital heart disease
Heart valve disorders
When combined with O2 forms NO2
164. Capillary smooth muscle dilation
◦ Gas molecule – can be delivered directly to the
pulmonary capillaries (selective vasodilatation)
◦ Systemic vasodilatation is avoided
No loss of blood pressure
165. Artificial membrane that mimics the AC
membrane’s function
◦ Used for refractory ARDS
Done with a apparatus outside the body
Venoarterial
◦ Provides cardiac and pulmonary support
◦ More dangerous (hemolysis, bleeding)
Venovenous
166. Technique
◦ Catheters are placed and 30 -80% of the blood is
pumped through a membrane oxygenator
◦ The patient is ventilated to maintain PaCO2
167.
168.
169. Liquid perfourocarbon (Perflubrontm)
◦ More soluble to oxygen
Approximately 50X carrying capacity
◦ Dense liquid
Moves easily
◦ Distributes throughout the lung effectively
There is no build up of pressure in one area
◦ Volatile solution (evaporates)
170. Technique
◦ Fill FRC with solution until a meniscus is seen in the
endotracheal tube
◦ Ventilate the patient
The liquid distributes itself throughout the entire
diffusion area of the lung
Alveoli remain open
Debris floats to the top of the solution and is easily
removed
Solution has an anti-inflammatory effect
Notas del editor
Critical thinking continued…DOCUMENTChangesRationaleOutcomeReassess the variables
Possible causes of cough receptor stimulation:Inflammatory: Infection, lung abscess, allergy, edema, drug reactionMechanical: Inhaled dusts, suction catheter, foodObstructive: foreign bodies, aspiration of nasal secretions, tumor or granulomas around the lungAirway wall tension: pulmonary edema, atelectasis, fibrosisChemical: Inhaled irritant gases, fumes, smokeTemperature: Inhaled hot or cold airEar: Tactile pressure in the ear canal (otitis media)Chronic persistent cough is caused most commonly by postnasal drip syndrome, followed by acute asthma, acute exacerbation of chronic obstructive pulmonary disease, allergic rhinitis, gastroesophageal reflux disease (GERD), chronic bronchitis, bronchiectasis, and other conditions such as left heart failure, bronchogenic cancer, and sarcoidosis.Associated symptoms of cough:WheezingStridorChest painDyspnea
Clear, colorless, like egg white NormalFrothy white or pink pulmonary edemaPurulent infection, pneumonia caused by yellow or green pseudomonasCopious advanced chronic bronchitis, bronchiectasisMucoid emphysema, early chronic bronchitis, asthmaBlood streaked or hemoptysis Bronchogenic carcinoma, TB, Chronic bronchitis(most common), PE, bronchiectasisHematemesis (vomiting blood) –determine source. Oropharynx, swallowed from respiratory tract. Esophagus or stomach, alcoholism or cirrhosis of the liver, or GI bleed.
Syncope – Dizziness and FaintingDizziness, blurred vision, weakness, syncope
Four classic VSTemperature, pulse, respirations, blood pressureAdditional observationsHeight, weight, LOC, level and type of pain, general appearancePulse oximetryTemp:oral range (97° to 99.5° F), daily variations (1° to 2° F) Lowest in morning; highest late afternoonAxillary: (96.7 to 98.5 F)Rectal: (98.7 to 100.5 F)Ear: Expected to be very close to rectal if measured correctlyFever Increases O2 consumption and CO2 productionO2 consumption and CO2 production increase 10% for each 1 C elevation in body temperature Pulse: evaluate rate, rhythm, strengthVolume of the pulseBounding, full, normal, weak, thready, absentPulsusparadoxusStrength decreases with inspirationAlternans = strong and weak pulsesFrequency of VS measurement depends on patient’s conditionBaseline measurementOn admissionAt beginning of each shiftBefore procedureAny time patient’s condition changesSensorium is a measure cerebral oxygenationEvaluation of time, place, and person“Oriented × 3”
CBC determines the number of circulating red and white blood cellsIn addition, the test determines the number and type of white blood cells present in the circulating bloodRed blood cells are also evaluated for their size and amount of hemoglobin presentTotal number of white blood cells in a known volume of blood important to knowAlso important to know distribution of white blood cell types: neutrophils, eosinophils, lymphocytes, basophils, monocytes In healthy people, neutrophils and lymphocytes make up majority of WBC countPlatelet Count Blood platelets: also called thrombocytesAbnormally low platelet count is called thrombocytopeniaThe lower the platelet count the more likely patient will have problems with bleedingRTs should check patient’s platelet count before performing an arterial punctureSodium is the primary cationNormal values 137 to 147 mEq/LSodium concentration regulated by the kidneysHypernatremia occurs from loss of waterHyponatremia caused by excessive water intake or sodium lossPotassium is the primary intracellular cationNormal values are 3.5 to 4.8 mEq/LHypokalemia occurs with decreased intake or increased lossIncreased or decreased potassium levels can lead to cardiac dysfunctionChloride The most common extracellular anionNormal values are 98 to 105 mEq/LHypochloremia occurs with severe vomiting and chronic metabolic alkalosisHyperchloremia occurs with certain kidney diseases and prolonged diarrheaBicarb (total CO2)Plays a major role in acid-base balanceElevation of bicarb occurs with metabolic alkalosisA decrease in bicarb occurs with metabolic acidosisCOPD patients who have chronic CO2 retention will have an elevated total CO2The two most common tests to check on renal functionNormal BUN is 7 to 20 mg/dlNormal creatinine is 0.7 to 1.3 mg/dlNeither test is sensitive to early kidney diseaseHeart failure also elevates the BUN
Assessment for malnutrition importantIncluding organ function and muscle wastingSerum albumin concentration most common<2.2 g/dl reflects severe malnutrition; shows chronic, not acute, changeAlso altered by sepsis, dehydration, trauma12 to 16 hours of insufficient carbohydrate intake will result in gluconeogenesisProcess of converting muscle and enzyme proteins into sugarThis leads to functional tissue lossIn starvation:Muscles lose endurance and strength (including those of respiration) Noted by decreased FVC, FEV1, and DLCO Diminished immune function because antibodies are proteinsCarbohydrate (sugar)Should be largest amount of dietary intakeComplex carbs in grains, vegetables, fruitsSimple sugars present in the above foods but primarily found in refined processed foodsPatients with severe COPD may do better with a lower-carbohydrate, higher-fat diet due to reduced CO2 production Protein should comprise 12% to 15% of intakeRecommended daily amount (RDA) varies0.8 g/kg for healthy individual 1.2 to 1.5 g/kg for average hospital patient2 to 2.5 g/kg for severe catabolic patientsNitrogen found only in protein amino acidsQuick estimate of protein catabolism is made by multiplying blood urea nitrogen (BUN) by 6.25Fat carries fat soluble vitamins: A, D, E, KImportant for immunity, clotting, antioxidants, etc.Fats twice as calorie dense as other nutrientsThus efficient for increasing caloric intake for patients on fluid restrictions Higher fat content may decrease dyspnea for COPD patients
Neurologic assessment evaluates:Mental statusCranial nerve functionMotor systemCoordinationSensory systemReflexes Neurologic system:Central nervous systemBrain: cerebrum, brainstem, cerebellumSpinal cordPeripheral nervous systemCranial nervesSpinal nervesSensorium is a measure cerebral oxygenationEvaluation of time, place, and person“Oriented × 3”Deterioration from restlessness to comaCerebral hypoxiaSide effect to medications or drug overdoseStatus of sensorium directs treatment planPatient cooperation, coordinationGlasgow Coma ScaleScale goes from 3 (deep coma) to 15 (fully awake)GCS of 12-15 = non-ICU observationGCS of 9-12 = significant insultGCS <9 = severe coma = requires endotracheal intubation
The two most common tests to check on renal functionNormal BUN is 7 to 20 mg/dlNormal creatinine is 0.7 to 1.3 mg/dlNeither test is sensitive to early kidney diseaseHeart failure also elevates the BUN
Tissue oxygenation depends on CaO2, cardiac output, and oxygen uptakeH.A.S.H.Hypoxic hypoxia – O2 cannot diffuse across the AC membrane (inability for oxygen to reach the blood)Anemic hypoxia- non functional hemoglobin (anemic or carbon monoxide poisoning) ( Can diffuse but not enough carriers)Stagnent hypoxia- hearts inability to pump out oxygenated blood ( Can diffuse, enough blood to carry, heart not pumping out)Histotoxic hypoxia- inability for the tissues to utilize the oxygen once it gets there ( Can diffuse, enough blood to carry, heart pumping, tissues can’t use O2)
Endotracheal tube placementAnalysis of CO2 eliminationDecreased need for arterial punctureCardiopulmonary assessmentCardiac arrestAdequacy of CPR
I ) Dead space… No CO2II) Gas mixing phase CO2 and Dead spaceIII) Alveolar Plateau… All CO2
Normal hemoglobin is
You are the evening shift respiratory therapist at your hospital and have been summoned to the emergency department. Lisa Camps, a 34-year-old woman, has just arrived in the emergency department after a motor vehicle accident. She is on a non-rebreathing mask at a flow rate of 12 L/min. The emergency department physician wants your assistance in assessing and managing Ms. Camps. Your assessment reveled the following about Ms. Camp’s cardiopulmonary status? Color – dusky Pupillary reaction – sluggish Respiratory rate and pattern – 28/bpm and laboredLevel of consciousness – semiconscious and combativePulse and blood pressure – 130/min, 130/90General appearance – Anxious, with bleeding from head lacerationChest auscultation – bilateral breath sounds diminished in the basesECG – sinus tachycardia with a rate of 130/minABG – pH 7.30, PCO2 50 torr, PO2 69 torr, HCO3 -25mEg/L
Twenty-four hour later, you are performing ventilator checks on Ms. Camp’s ventilator when the high-pressure alarm begins to sound with each breath. Ms. Camp is in respiratory distress with a respiratory rate of 32/bpm. Which of the following would you evaluate at this time? Mark all that apply.
Ventilator function – functioning normally with appropriately set parametersSputum color – clearTemperature 37°CMIP -60 cmH2ONo obstruction because the suction catheter is inserted and advanced into the ETT.Breath sounds absent on the rightGag reflex intact Bowel Sound normalPapillary reaction normalHyperresonant sound over right upperIncreased resistance with difficulty to manually ventilateAsymmetrical chest movement, with left lung expanding more than the right lung Heart rate 130/minTrachea deviated to the left of midline
One week later, Ms. Camp remains on the ventilator on AC with a Vt of 550 ml and an FiO2 of 0.35. On these settings her ABG results are pH 7.42, PCO2 41 torr, PaO2 90 torr, HCO3 24mEq/L. She has normal results on her chest x-ray and her ICP in 5 mmHg, Temp 37°C, MIP -31 cmH2O, RR 14/bpm, spontaneous Vt 350. Which of the following would you recommend to evaluate the patient readiness to wean? Temp. – 37MIP – 31Spontaneous RR 14/bpmSpontaneous Vt 350
Which of the following would you recommend at this time?Maintain present settingsPlace on flow-by and 50% O2Place on SIMV, RR 10/bpm, VT 600, FIO2 0.40,PS 10 cmH2OPlace on SIMV, RR 4/bpm, VT 600, FIO2 0.40,PS 10 cmH2OExtubate and place on 40% aerosol mask
One hour later, ABG results are pH 7.38, PaCO2 38 torr, PaO2 87 torr, HCO3 -25mEq/L, SaO2 97%, RR 16/bpm and spontaneous Vt 375ml. Which of the following would you recommend at this time?Decrease the Vt by 100 mlMaintain current settings and monitor closelyIncrease the PS to 15 cm H2ODecrease the RR by 2/bpmPlace on flow-by and PS of 5 cmH2O
Assessing the position of the ETT Position of the carinaMay be directly visualizedCan be estimated be at the level of T 5 to T6
A 55 year-old man arrives at the clinic at the complaining of chills, fever and chest pain on inspiration. He is coughing up rusty-colored sputum. He admits to a history of heavy smoking and regular use of alcoholic beverages. Physical examination reveals a heart rate of 125, respiratory rate of 30 and a temperature of 104º F. He has inspiratory crackles in the right lower lobe. Blood gases reveal a pH of 7.34, PaCo2 of 50 and PaO2 of 50
A 70 year-old man’s chief complaint is dyspnea on exertion. He has a smoking history of two packs per day for the past 50 years. He has a barrel-shaped chest and decreased breath sounds. His chest radiograph shows hyperinflation, especially in the apices; flattened diaphragms; and an enlarged heart. He admits to a morning cough with significant sputum production.
RSBI is Endurance! Remember that you might have the muscle strength but if it is not accompanied with endurance your patient cannot come off the Vent. MVV also represents Endurance!MVVN = 120 to 180 liters per minuteShould be 2x the VE
A patient is intubated and is on the ventilator following a head injury. On the third day following his craniotomy, he develops a fever. During routine suctioning the RT notices his secretions are thick and yellow. Breath sounds are decreased in the left lower lobe.
Volume is being controlled here so your Volume waveform will be the same.Pressure will vary with each breath and will also reflect peep that is set as well as autopeepFlow waveform will be the best way to see if the patient is auto peeping. If autopeep is present then you will see the breath start below baseline.
Here you can see on your pressure waveform that the patient is able to trigger their breath… Remember that just means to start inspiration. The ventilator is still controlling the delivery of the breath.
Here we have both mandatory breaths as well as spontaneous breaths. The spontaneous breaths are with out pressure support.
Notice the difference in the spontaneous breaths with pressure support vs. the spontaneous breaths with out pressure support on the previous slide.
When in pressure control, remember that if you have a longer I time you will be able to increase your tidal volume. To increase your I time you will decrease your flow. Think of FLOW as speed, how fast is the breath being delivered.
Note, no patient effort
Need to add PEEP
Increase the FLOW
A mathematics instructor with a history of CHF is admitted with a complaint of pain on inspiration. Her respirations are rapid and shallow and her heart rate is 104. The pulse oximeter shows a saturation of 93% on room air. Breath sounds are very decreased on the right side, with crackles in the left base. Chest wall movement is markedly less on the right. The chest radiograph shows opacification of the right lung, with shift of mediastinal structures to the left. Diagnostic percussion reveals a dull note on the right.
Based on height & thoracic configurationMen IBW = 106 + 6(Ht – 60)Women IBW = 105 + 5(Ht – 60)Height expressed in inchesIBW is calculated in poundsThen IBW Lbs./2.2 = Kg
A tall, young male respiratory care instructor, is admitted with a complaint of pain on inspiration. His respirations are rapid and shallow and his heart rate is 104. The pulse oximeter shows a saturation of 93% on room air. Breath sounds are very decreased on the right side and clear in the left base. Chest wall movement is markedly less on the right. The chest radiograph shows a dark area without lung markings on the right side with a shift of mediastinal structures to the left. Diagnostic percussion reveals increased resonance on the right side.
Ms. Nelson is a 47 year-old woman who was found unconscious on the floor of the apartment by a relative. Empty bottles of diazepam (Valium), effxor (antidepressant), and beer cans were nearby. The relative dialed 911, and the patient was transported to a local emergency room. During transportation, the patient had an adequate pulse rate but required ventilatory assistance with a bag-valve mask on oxygen. An ABG was obtained immediately, and a drug screen was ordered in the emergency room.
Ms. Nelson is a 47 year-old woman who was found unconscious on the floor of the apartment by a relative. Empty bottles of diazepam (Valium), effxor (antidepressant), and beer cans were nearby. The relative dialed 911, and the patient was transported to a local emergency room. During transportation, the patient had an adequate pulse rate but required ventilatory assistance with a bag-valve mask on oxygen. An ABG was obtained immediately, and a drug screen was ordered in the emergency room.
Physical ExaminationGeneral. An unconscious, slightly obese female with an 8.0-mm endotracheal tube in place being ventilated with a hand resuscitator; Ewald tube in left nostril; gastric lavage fluid containing a large number of pill fragments; strong smell of alcohol; patient approximately 5 foot, 8 inches and 155 pounds.Vital Signs. Pulse 124/minute, respiratory rate 12 to 16/minute with bag-valve mask, body temperature 35.3°C (95.6°F), blood pressure 120/75 mm HgHEENT. No signs of trauma; pupils dilated with sluggish response to light.Heart. Normal heart sounds with no murmurs.Lungs. Breath sounds clear except in right lower lobe, where inspiratory crackles are heard.Abdomen. Soft, obese, with no organomegaly or tenderness; bowel sounds present, but hypoactive.Extremities. Warm to palpation with no edema, clubbing, or cyanosisInitial ABG Findings. (while patient is being ventilated with no FiO2 of 1.0 via a bag-valve mask prior to intubation). pH 7.28, PaCO2 54 mm Hg, PaO2 135 mm Hg, Sao2 99%, HCO3 = 26 mEq/liter
Physical ExaminationGeneral. An unconscious, slightly obese female with an 8.0-mm endotracheal tube in place being ventilated with a hand resuscitator; Ewald tube in left nostril; gastric lavage fluid containing a large number of pill fragments; strong smell of alcohol; patient approximately 5 foot, 8 inches and 155 pounds.Vital Signs. Pulse 124/minute, respiratory rate 12 to 16/minute with bag-valve mask, body temperature 35.3°C (95.6°F), blood pressure 120/75 mm HgHEENT. No signs of trauma; pupils dilated with sluggish response to light.Heart. Normal heart sounds with no murmurs.Lungs. Breath sounds clear except in right lower lobe, where inspiratory crackles are heard.Abdomen. Soft, obese, with no organomegaly or tenderness; bowel sounds present, but hypoactive.Extremities. Warm to palpation with no edema, clubbing, or cyanosisInitial ABG Findings. (while patient is being ventilated with no FiO2 of 1.0 via a bag-valve mask prior to intubation). pH 7.28, PaCO2 54 mm Hg, PaO2 135 mm Hg, Sao2 99%, HCO3 = 26 mEq/liter
Physical ExaminationGeneral. An unconscious, slightly obese female with an 8.0-mm endotracheal tube in place being ventilated with a hand resuscitator; Ewald tube in left nostril; gastric lavage fluid containing a large number of pill fragments; strong smell of alcohol; patient approximately 5 foot, 8 inches and 155 pounds.Vital Signs. Pulse 124/minute, respiratory rate 12 to 16/minute with bag-valve mask, body temperature 35.3°C (95.6°F), blood pressure 120/75 mm HgHEENT. No signs of trauma; pupils dilated with sluggish response to light.Heart. Normal heart sounds with no murmurs.Lungs. Breath sounds clear except in right lower lobe, where inspiratory crackles are heard.Abdomen. Soft, obese, with no organomegaly or tenderness; bowel sounds present, but hypoactive.Extremities. Warm to palpation with no edema, clubbing, or cyanosisInitial ABG Findings. (while patient is being ventilated with no FiO2 of 1.0 via a bag-valve mask prior to intubation). pH 7.28, PaCO2 54 mm Hg, PaO2 135 mm Hg, Sao2 99%, HCO3 = 26 mEq/liter
PATIENT MUST BE SEDATED AND PARALYZED IN THIS MODE! You do not want your patient to cough in this mode!!! It is such an unnatural way of breathing, inspiring for longer than you are expiring, that you must be put in pressure control as well.
High Frequency Jet Ventilation:Rates are described as Frequency. Your Frequency is expressed in Hertz (Hz) 1Hz is equal to 60 breaths a minute.Unlike your conventional ventilators where your rate deals with ventilation, in HFJV your “frequency” deals with oxygenation. To fix ventilation in HFJV you would adjust the “driving pressure”. Ex. Increase the driving pressure to blow off CO2.
Frequency and amplitude are used here. To blow off CO2 you would increase your amplitude. We are looking for a “wiggle” Initial settings: Amplitude 6-7 and we can start at a Frequency of 2.5 Hz increase to improve oxygenation. In this mode we have a nice smooth laminar flow coming into the lungs keeping the alveoli open (increasing MAP or PAW) while at the same time the CO2 is “Bumping or Vibrating” out the sides achieving constant gas exchange.
In this mode we do not have RR or Vt. We have two different levels of pressure and time.To set your P high: you will set it at whatever the Pplat was on the conventional ventilator but no greater than 35cmH2OTo set your T high: you will need to have a frequency to which you will get a TCT. Frequency should be between 9-12b/mExample:Frequency 12 TCT = 60/12 TCT= 5seconds. We now have 5 seconds to work with between or time high and our time low.Time high should be set between 4-6 secondsTime low should be set between 0.1-0.9 secondsSo if we have a TCT of 5 seconds we can set our Time high at 4.3 seconds and our Time low at 0.7 seconds. Together they make up our TCT.A true APRV ratio is 4:1 but don’t get this confused with inverse ratio. Your patient does NOT need to be paralyzed and sedated to be in APRV. They are actually allowed to spontaneously breathe during the T high while being held open at the P high. Remember that when your patient is intubated and able to breath spontaneously we must add pressure support to overcome the resistance of the tube. You do not need to be spontaneously breathing to be in this mode but you are able to.
T PEEP stands for time low hereIn this mode we do not have RR or Vt. We have two different levels of pressure and time.To set your P high: you will set it at whatever the Pplat was on the conventional ventilator but no greater than 35cmH2OTo set your T high: you will need to have a frequency to which you will get a TCT. Frequency should be between 9-12b/mExample:Frequency 12 TCT = 60/12 TCT= 5seconds. We now have 5 seconds to work with between or time high and our time low.Time high should be set between 4-6 secondsTime low should be set between 0.1-0.9 secondsSo if we have a TCT of 5 seconds we can set our Time high at 4.3 seconds and our Time low at 0.7 seconds. Together they make up our TCT.A true APRV ratio is 4:1 but don’t get this confused with inverse ratio. Your patient does NOT need to be paralyzed and sedated to be in APRV. They are actually allowed to spontaneously breathe during the T high while being held open at the P high. Remember that when your patient is intubated and able to breath spontaneously we must add pressure support to overcome the resistance of the tube. You do not need to be spontaneously breathing to be in this mode but you are able to.
Also known as the “drop and Stretch” Drop down your P high and Stretch out your T high until you get to CPAP.
Adaptive Support Ventilation is a novel ventilation mode, a closed-loop control mode that may switch automatically from a PCV-like behaviour to an SIMV-like or PSV-like behaviour, according to the patient status. The operating principles are based on pressure-controlled SIMV with pressure levels and SIMV rate automatically adjusted according to measured lung mechanics at each breath. ASV provided a safe and effective ventilation in patients with normal lungs, restrective or obstructive diseases.http://www.ncbi.nlm.nih.gov/pubmed/12029247You can set what percentage of minute ventilation to deliver. So if your patient is on 100% Ve and they are still acidic you would increase the Ve %
