Chapter 13-15 review - mechanical vent

where are the beta 2 receptors found?

-sympathetic branches (adrenergic receptors)

-in the lungs

(bronchodilation, peripheral vasodilation, and decreased gastrointestinal activity)

what are the adverse effects of adrenergic bronchodilators?

-tachycardia

-palpitations

-skeletal muscle tremors

-nervousness

is ipratropium bromide indicated for emergency use?

No, it is not a first line of medication

what are corticosteroids used for?

-anti-inflammatory agents (antibiotics) for managements of bronchoconstriction and airflow obstruction due to airway inflammation

-should NOT be given alone during asthma attack due to bronchodilation effects

are corticosteroids used for bronchoconstriction?

No, they are NOT bronchodilators

how are corticosteroids delivered?

-oral, IV, and inhalation (SVN, DPI, MDI)

-SVN/MDI can be given via ventilator

-DPI cannot be given via ventilator

-hormones released from cortex of adrenal gland

describe corticosteroids

-1st line of defense for chronic asthma and other long-term airway inflammation conditions

-effective for asthma and chronic bronchitis

-anti-inflammatory drugs

how do you give an MDI to a vented patient?

• through a spacer

• -Vt >500mL

-Longer inspiratory time by using a lower inspiratory flow

-Actuate dose at the onset of inhalation (no delay)

-The number of puffs is dependent on the type of MDI medication (usually 2-3 times the normal dose)

-can be enhanced by synchronization of actuation of MDI with onset of inspiratory flow, a longer inspiratory time, and a slower inspiratory flow

what are the benefits of paralytics during mechanical ventilation?

-reduced combativeness and agitation

-relaxation of respiratory muscles

-increased chest wall compliance

-synchronization during unnatural modes of ventilation (inverse I:E)

-prevention of hypoxemia associated with increased WOB

-decrease ICP caused by excessive movement

what are the names of the commonly used paralytics?

Depolarizing

-Succinylcholine

Nondepolarizing

-Pacuronium

-Atracurium

-Vecuronium bromide

-Rocuronium

what is another name for Succinylcholine?

-Anectine

-Quelicin

what is another name for Pancuronium?

-Pavulon

what is another name for Atracurium?

Tracrium

what is another name for Vecuronium bromide?

Norcuron

what is another name for Rocuronium?

Zemuron

what are the common benzo medications used in mechanical ventilation?

-Diazepam (valium)

-Lorazepam (Ativan)

-Midazolam (Versed)

describe propofol

-drops BP

-strict aseptic techniques are essential because the fat emulsion provides an excellent medium for microbial growth

-provides analgesia only at high dose (assessment of adequate pain control is necessary at lower doses)

-additive hypotension may develop when used with opioid analgesics

-ideal for intubated patients because it does not promote salivation or vomiting

-dosage should be reduced gradually to avoid sudden return of pain and environmental disorientation

-IV drug administered together with other anesthetics to produce and maintain anesthesia

what are signs of withdraw from medications or alcohol?

-agitation

-tremors

-sweating

-nausea

-seizures

-tachycardia

-delirium

what determines if a patient has ALI or ARDS?

-acute onset

-noncardiogenic pulmonary edema (PCWP < or equal 18mmHg) (>18mmHg could be cardiogenic from wedge pressure)

-severe hypoxemia (with or without PEEP)

-ALI: PaO2/FiO2 ratio < or equal 300mmHg

-ARDS: PaO2/FiO2 ratio < or equal 200mmHg

what are some ways to reduce VAP

-maintain proper cuff pressure to minimize aspiration

-change ventilator circuits every 7 days

-change HME every 24 hours

-change inline suction every 3 days

-use ETT with dorsal lumen for subglottic secretion removal

what are ways to prevent VAP?

-exercise good hand hygiene or wear gloves

-elevate head of bed at 30-45 degree angle at ALL times

-change ventilator circuit when visibly soiled

-use noninvasive ventilation (without artificial airway)

-schedule sedative vacation for 6-8 hours daily

what is a rationale for exercising good hand hygiene

-reduce nosocomial infection

-wash hands with soap and water or use alcohol gel before/after patient contract

-avoid wearing rings during work

what is a rationale for elevation of head of bed at 30-45 degree angle at all times

-reduce incidence of aspiration

what is a rationale for changing ventilator circuit when visibly soiled or malfunctioned

-reduce incidence of contamination with water condensate or secretions during circuit change

what is a rationale for the use of noninvasive ventilation with face mask

-avoid direct access of pathogens to lower respiratory tract

what is a rationale for scheduling sedation vacation every 6-8 hours daily

-allow weaning assessment and early extubation

what is a rationale for initiating early weaning from mechanical ventilation

-reduce exposure of lower airway to pathogens and ventilator-induced lung injuries

what is the rationale for following sterile techniques in suctioning and preventing contamination of endotracheal or tracheostomy tube

-reduce exposure of lower respiratory tract to pathogens

what is the rationale for performing good oral care or decontaminate oropharynx

-reduce exposure of lower respiratory tracts to pathogens

what is the rationale for using oral feeding tube

-use of nasal feeding tube may cause sinusitis, a condition associated with VAP

what is the rationale for using an ETT with an ultrathin and tapered-shape cuff membrane

-reduce incidence of aspiration

what is the rationale for using ETT coated with silver or antimicrobial agents

-provide protection against some pathogens

what is the rationale for using ETT with separate dorsal lumen above the cuff for subglottic secretion drainage

-reduce incidence of aspiration (routine use is not supported)

what does HIE stand for?

Hypoxic-Ischemic Encephalopathy

what is HIE?

condition caused by severe cerebral hypoxia leading to damage to the cells and neurons of the brain and spinal cord

what are the 3 broad categories of acute brain hypoxia

-inadequate ventilation and oxygenation (respiratory arrest, CO poisoning)

- inadequate perfusion (cardiac arrest, shock)

-decrease in cerebral perfusion pressure (decrease in mean arterial pressure or increase in intracranial pressure) (lack of blood flow to the brain could cause HIE)

-brain is dependent on oxygen and glucose levels provided by the blood

what are symptoms of HIE?

-difficulty concentrating or paying attention

-poor judgement

-euphoria

-extreme lethargy

-seizures

-coma

what are some treatments for HIE?

-oxygenation

-ventilation and perfusion

-seizure control

-therapeutic hypothermia

-hyperbaric oxygen therapy

describe global ischemia

-of the brain is a lack of cerebral blood flow due to low cerebral perfusion pressure

-perfusion-related (cardiac arrest, hypotension)

-non-perfusion-related (traumatic brain injury, increase in ICP)

how long does it take for anoxia to set in?

within 5 minutes

-loss of consciousness can happen 15-30 seconds of oxygen deprivation

-

what is the normal CPP?

70-80mmHg

-mortality increases by 20% for every 10mmHg decrease in CPP

-Therapeutic hypothermia (32-34*C) helps to improve the neurological outcomes of post-arrest patient (brain will slow down if it gets cold)

describe what happens if there is a decrease in CPP due to brain injury

-ICP is increased due to swelling and congestion of the brain with fluid and blood in a rigid compartment (skull)

-increase in ICP lowers the CPP

what is the equation for finding a decrease in CPP?

decrease CPP = MAP - increase ICP

CPP may be improved by increasing what?

MAP via

-fluid administration

-vasopressors (make BP better to increase CPP)

how can TBI's occur?

-motor vehicle crashes (majority younger than 35)

-falls (majority older than 65)

-assaults

-sports-related injuries

-penetrating trauma

-explosive blasts

-combat injuries

what is the number for individuals with severe head injury to become permanently disabled?

-almost 100% of patients

-2/3 of those with moderate head injury

how many new cases in the US of TBI are there a year?

600,000

how much space does the brain occupy?

85-90%

-intravascular cerebral blood volume accounts for 10% of this volume

-cerebrospinal fluid accounts for 3% of this volume

-low compliance skull does not move

describe the skull

-rigid

-has a capacity of 1,500mL

-very low compliance and cannot tolerate rapid volume expansion

what is the normal for intracranial pressure (ICP)?

8-12mmHg

-an increased ICP will lower the cerebral perfusion pressure (CPP)

bronchodilation may be induced by all of the following mechanisms expect

stimulating the parasympathetic branch of the autonomic nervous system

a patient who has been using Theo-Dur at home states that she experiences palpitations, nausea, vomiting, headache, and agitation each time after taking the medication. The proper management technique for this patient includes monitoring of the ____ level and titrating the dosage to a therapeutic range of ____

serum theophylline; 5-15mcg/mL

an asthmatic patient who has been using Ventolin for several months complains of shortness of breath and states the "the Ventolin is not working anymore." The physician asks a therapist for suggesting. The therapist should recommend a trial use of:

Vanceril

which of the following is not an indication for using a neuromuscular blocking agent?

facilitate endotracheal suctioning

3 multiple choice options

Succinylcholine (Anectine, Quelicin) is a ____ neuromuscular blocking agent. It induces muscle blockade by ____

depolarizing, binding to the receptor sites and causing sustained depolarization

all of the following are potential complications of a neuromuscular blocking agent except:

oversedation

a patient who has been Norcuron one hour ago is recovering in the SICU. The physician wants to know whether neuromuscular blockade reversal has occurred. The therapist should check all of the following except:

serum acetylcholine level

3 multiple choice options

a mechanically ventilated patient has been receiving diazepam (Valium) for better tolerance of mechanical ventilation and related procedures. The cardiovascular adverse effects for his patient may include:

decreased cardiac output

3 multiple choice options

the Ramsay Scale is commonly used to assess the degree of:

sedation

inadequate pain control may lead to all of the following complications except:

increased immune function

3 multiple choice options

a patient is given nalozone upon returning from surgery. You may conclude that the patient has received too much ____ during surgery

opioid analgesic

for seizure disorders and control of elevated intracranial pressure, ____ may be useful

barbiturate

3 multiple choice options

Haloperidal (Haldol) should be considered for controlled delirium

after reversible causes of delirium have been ruled out

dexmedetimidine is a GABA agonist that provides all of the following pharmacological effects except:

respiratory stimulation

among other applications, inhaled nitric oxide (iNO) is used to treat ______. When iNO is combined with oxygen, _____ if formed

pulmonary hypertension; nitrogen dioxide

what is the purpose of a RM? (recruitment maneuver)

-to determine optimal PEEP to improve oxygenation by recruiting collapsed alveoli and increasing lung capacity

-a combination of FiO2 and PEEP to minimize airway pressures and optimize oxygenation

-it is used on patients with severe pulmonary edema and who are most at risk of dying from refractory hypoxemia due to ALI and ARDS

what is anoxia?

when your brain completely loses its oxygen supply

-a lack of cerebral circulation depletes the neuronal oxygen stores within 20 seconds and leads to unconsciousness

clinical conditions associated with development of ARDS: direct lung injury

-pneumonia

-aspiration

-inhalation of toxins

-near drowning

-pulmonary contusion

-fat embolism

clinical condition associated with development of ARDS: indirect lung injury

-sepsis

-severe trauma

-acute pancreatitis

-cardiopulmonary bypass

-transfusion of blood products

-drug overdose

a PaO2/FiO2 of 20mmHg is a characteristic of patients with:

acute respiratory distress syndrome

bilateral infiltrates on the chest radiograph and elevated pulmonary capillary wedge pressure (22mmHg) are signs of:

cardiogenic pulmonary edema

in order to reduce the risk of lung injuries during mechanical ventilation, the ARDSNet recommends that the plateau pressure be kept below

30cmH20

the physician wants to implement permissive hypercapnia for a mechanically ventilated patient. The therapist should reduce the ____ setting in the range of ______

tidal volume; 4-7mL/kg

The ARDS Net initial settings for patients with ARDS include all of the following except:

use of Vt as low as 7mL/kg to maintain Pplat <30cmH2O

3 multiple choice options

the decremental recruitment maneuver is done to obtain a patient's

optimal PEEP

a patient has been a score of 8 using the modified clinical pulmonary infection score chart. This means that the patient is likely to require

antibiotics

the RT department is implementing a policy to reduce the incidence of VAP. Based on research findings, which of the following methods should not be included in the policy?

change ventilator circuit every 24 hours

a patient's calculated cerebral perfusion pressure (CPP) is 6ommHg (normal 70-80mmHg). What can be done to increase the patient's CPP?

-increase the mean arterial pressure

-decrease the intracranial pressure

a patient in the emergency department who was involved in a motor vehicle crash has a Glasgow Coma scale score of 7. This means that the patient has

severe brain injury

based on a study published in trauma.org, the ICP may be lowered by _____ a patient to a PaCO2 level of _____ during the first 24 hours of mechanical ventilation

hyperventilating; 26mmHg

bronchodilation may be induced by all of the following mechanisms except:

stimulating the parasympathetic branch of the autonomic nervous system

A patient who has been using Theo-Dur at home states that she experiences palpitations, nausea, vomiting, headache, and agitation each time after taking the medication. The proper management technique for this patient includes monitoring of the _______ level and titrating the dosage to a therapeutic range of _______.

serum theophylline ; 5-15mcg/mL

An asthmatic patient who has been using Ventolin for several months complains of shortness of breath and states that "the Ventolin is not working any more." The physician asks a therapist for suggestion. The therapist should recommend a trial use of:

Vanceril

Which of the following is not an indication for using a neuromuscular blocking agent?

facilitate endotracheal suctioning

Succinylcholine (Anectine, Quelicin) is a _______ neuromuscular blocking agent. It induces muscle blockade by _______.

depolarizing, binding to the receptor sites and causing sustained depolarization