Advanced Methods of Respiratory Support

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Flashcards on Advanced Methods of Respiratory Support, created by Elizabeth Then on 28/08/2018.
Elizabeth Then
Flashcards by Elizabeth Then, updated more than 1 year ago
Elizabeth Then
Created by Elizabeth Then over 5 years ago
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The Respiratory tract Pulmonary functional unit Ciliated mucous membrane
Goals of the respiratory system - transport oxygen from atmosphere to alveoli, where it is collected by HB and transported to active tissue - O2 is used with mitochondria to support aerobic metabolism by-product is CO2 -CO2 is transported out of the body in blood, across alveolar membrance and expired
Non- Respiratory functions of the lungs - Filtration of micro-emboli - Metabolic function of lungs: - inactivation of damaging enzymes (Alpha 1 antitrypsin) - alteration of hormonal levels (angiotensin 1 converted to angiotensin 2) - involvement in lipid metabolism - acts as a reservoir for blood - storage of megakaryocytes
Oxygen Delivery - step by step process 1 - atmosphere to alveoli (Ventilation) 2- Alveoli to blood (Diffusion) 3 - Transport to gases in blood (HB binding) 4 - Convection (Cardiovascular) 5 - Blood to tissues (Diffusion)
Tissue and cellular oxygenation relies on: Oxygen delivery Pulmonary gas exchange Oxygen consumption
Respiratory system consists of: - Ventilatory pump (Pleura, peripheral nerve, bones, muscles, soft tissues) - Gas exchanger - Respiratoy controller (Automatic, behavioural, sensory)
Respiration Process of supply and demand Supplied oxygen and carbon dioxide are elimiinated
Oxygen delivery depends on: - Ventilation - Diffusion of o2 into the blood - Binding with hb - Adequate cardiac output - Diffusion into the cell - DO2 = HB x 10 x sao2 x1.3 x co
Laryngospasm -Precipitating causes: airway irritation and or obstruction - failure of anaesthetic delivery clinical signs: - Inspiratory stridor/airway obstruction - increased inspiratory efforts/ trachel tug
Laryngospasm management - 100% oxygen - chin lift and jaw thrust - positive pressure
Definition of respiratory failure PAO2 of 60mmhg or less when the pt is receiving is receiving an inspired oxygen concentration of 60% or greater
Classification of respiratory failure Hypoxaemic - oxygenation failure, less than 60mmhg Hypercapnic - Ventilatory failure, greater than 50mmhg acute - minutes to hours chronic - several days or longer
Hypoxaemic respiratory failure - ventilation-perfusion VQ mismatch - Shunt - Diffusion limitation - Alveolar hypoventilation
Hypercapnic respiratory failure - airways and alveoli - central nervous system - chest wall - neuromuscular conditions - tissue oxygen needs
Acute Respiratory Distress syndrome ARDS - injury or exudate phase - clinical progression - fibrotic phase
ARDS stages of oedema formation in ARDS, - Alveoli oedema occurs when the fluid crosses then blood- gas barrier
Complications of ARDS -nosocomial pneumonia - Barotrauma - Volu-pressure trauma - physiological stress ulcers - renal failure
Respiration versus ventilation External respiration (Ventilation) - transfer of gas to enable the exchange of carbon dioxide and oxygen occurring in the alveoli Internal Respiration (Respiration) - consumption of oxygen and production of carbon dioxide within the tissues
Principles of ventilation Ventilation therapy is provided via non invasive or invasive means and usually with positive pressure breaths
Non-invasive ventilation - NIV delivers positive pressure breaths to a spontaneous breathing patient by face or nasal mask within an airtight seal - Positive end expiratory pressure (PEEP) - Bilevel positive airway pressure (BiPAP) - Continuous positive airway pressure (CPAP)
Optimising success: Initial application technique - good tolerance without frequent intervention - Titrate to achieve and maintain patient in a 'zone of comfort' - Secure the mask and evaluate leak
Recognising failure of interventions - poor tolerance - PaO2/FiO2 less than 175 after 1 hour - Worsening PH and PACo2 -Haemodynamic instability - reduction in loss of consciousness
Complications of NIPPV - Drying of eyes - nasal bridge ulceration - leaks leading to hypoventilation - sleep disturbances
Invasive ventilation - inability to protect airway - inadequate breathing pattern - inability to sustain adequate oxygenation for metabolic demands - hypercarbia
Gold standard ETT
Components of a ventilator - pneumatic system: - inspiratory ventilator circuit - expiratory valve closes or partially closes - Electronic system: - microprocessor: insp/exp valve - Information/monitoring systems - ventilator alarms
Modes of ventilation and breath delivery - breath type and breath delivery during mechanical ventilation constitute mode of ventilation Factors to consider are: - type of breath - targeted control variable (volume or pressure) - Timing of breath delivery (Mandatory or spontaneous)
mandatory breaths Ventilator controls timing, patient triggered, volume targeted and volume cycled
Spotaneous breaths patient controls timing and tidal volume, the volume and pressure of both delivered is based on patient characteristics not a set value
Assisted breath Characteritics of above, but all or part of breath is generated by ventilator, which does part of WOB for patient. - A target pressure is set by clinician and ventilator delivers the set pressure above baseline pressure to assist breathing effort
Modes of ventilation - volumes modes: volume controlled (VC), Synchronised Intermittent Volume Controlled (SIMV) - Pressure modes: Pressure controlled (PC), pressure support (PS) - Others: PEEP, CPAP, BIPAP, high frequency
Ventilator setting for specific patient situations COPD: - maximise patient ventilator synchrony and decrease WOB and anxiety - Asthma: most difficult to ventilate, secretions lead to oedema, tight airways make gas movement impossible in some areas ARDS: Increase vascular permeability, lung water and protein, issues with oxygenation and ventilation
Sedated and critically ill patients with resp failure rely on nurse to: - correct circuit disconnections - provide suction - monitor ventilator effects - observe for complications of ventilation - optimise sedation level
Nursing care - check ventilation order against what is giving - Check ETT length - check pilot ballon - check resp status - check for leaks in system
Ventilator bundle - series of interventions that should be done on each mechanically ventilated patient to move this closer to removal of mechanical ventilation purpose: to eliminate ventilator associated complications and reduce duration of ventilator, risk of death
Complications associated with ventilation - VAP, ALI - na and h20 imbalance - gastro bleeding - resp muscle weakness - PTS
Mutisystem effects of positive pressure ventilation - volutrauma/ barotrauma/ alectrauma= increase gas flow to nodependent lund, increase dead space - resdistribution of pulmonary blood flow - oxygen toxicity - ventilator associated pneumonia , altered VQ mismatching
Effects of PPV cardiovascular decrease CO, SV, Right ventricular preload clinical manisfestations - decrease BP
Effects of PPV Neurovascular CPP = MAP - ICP (Difference b/w MAP and IP clinical manisfestations: possible increase in ICP, altered LOC
Effects of PPV Renal Redistribution of blood flow to kidneys clinical manisfestations: decrease UO, increase NA and creatinine
Effects of ppv Gastrointestinal Decrease blood flow to intestinal viscera clinical manifestations - increase risk of ulcer, GI bleed
Ventilator bundle of care - DVT prophylaxis TEDS gastric bleeding prophylaxis Head of bed elevation sedation vacation nutrition Tight glycaemic control 'FASTHUG'
Pharmacology - Neuromuscular blocking agents (atracurium/rocuronium/vecuronium) - Anaesthetic agents (Propofol/Thiopentone) - Sedation agents (Midazolam) - Opioid analgesics (Morphine/fentanyl)
Weaning - weaning methods: T-Piece still around SIMV PSV
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