3 - Establishing Need for Mechanical Ventilation

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43 Terms

1
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acute respiratory failure (ARF)

ventilation is not adequate to maintain gas exchange and acid-base balance

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goals of mechanical ventilation (MV)

  • physiological

  • support/manipulate pulmonary gas exchange

  • increase lung volume

  • reduce WOB

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goals of mechanical ventilation (MV)

  • clinical

  • reverse ARF

  • reverse respiratory distress

  • reverse hypoxemia

  • prevent/reverse atelectasis and maintain FRC

  • reverse respiratory muscle fatigue

  • allow sedation/paralysis

  • reduce systemic/myocardial O2 consumption

  • minimize associated complications

  • reduce mortality

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recognition of respiratory distress

  • assess LOC

  • assess appearance and texture of skin

  • evaluate vital signs

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types of ARF

  • hypoxemic

  • hypercapnic

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causes of hypoxemic ARF

  • V/Q mismatch

  • diffusion defects

  • right-to-left shunt

  • alveolar hypoventilation

  • aging

  • decreased inspired O2

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causes of hypercapnic ARF

  • ventilatory pump failure

  • CNS defects

  • neuromuscular defects

  • increased WOB

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manifestations of mild/moderate hypoxemia

  • tachypnea

  • dyspnea

  • pallor

  • tachycardia

  • mild HTN

  • restlessness

  • disorientation

  • headache

  • lethargy

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manifestations of severe hypoxemia

  • tachypnea

  • dyspnea

  • cyanosis

  • eventual bradycardia

  • eventual hypotension

  • somnolence

  • confusion

  • blurry vision

  • loss of consciousness

  • eventual coma

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manifestations of mild/moderate hypercapnia

  • tachypnea

  • dyspnea

  • tachycardia

  • HTN

  • vasodilation

  • headache

  • drowsiness

  • dizziness

  • confusion

  • sweatiness

  • redness

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manifestations of severe hypercapnia

  • tachypnea → bradypnea

  • eventual hypotension

  • hallucinations

  • hypomania

  • convulsions

  • loss of consciousness

  • coma

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causes of CNS disorders

  • drugs

  • tumors

  • stroke

  • head trauma (cerebral bleed, ↑ICP)

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causes of neuromuscular disorders

  • motor nerve damage

  • faulty nerve impulse

  • muscle dysfunction

  • drugs

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thresholds for neuromuscular disorders

  • MIP ≤ −20 to −30 cmH2O

  • VC < 10-15 mL/kg

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causes of increased WOB

  • respiratory muscle fatigue

  • airway obstruction

  • restriction

  • severe chest trauma

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MIP/NIF

  • normal range

−100 to −50 cmH2O

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MIP/NIF

  • critical

−20 to 0 cmH2O

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MEP

  • normal value

100 cmH2O

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MEP

  • critical range

< 40 cmH2O

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VC

  • normal range

65-75 mL/kg

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VC

  • critical range

< 10-15 mL/kg

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VT

  • normal range

5-8 mL/kg

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VT

  • critical range

< 5 mL/kg

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RR / f

  • normal range

12-20 breaths/min

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RR / f

  • critical range

> 35 breaths/min

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FEV1

  • normal range

50-60 mL/kg

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FEV1

  • critical range

< 10 mL/kg

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PEFR

  • normal range

350-600 L/min

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PEFR

  • critical range

75-100 L/min

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other physiological measurements

  • PaCO2

  • PaO2

  • SpO2

  • CaO2

  • PaO2/PAO2

  • PaO2/FiO2

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treatment for arterial hypoxemia

  • hypoventilation

increase alveolar ventilation

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treatment for arterial hypoxemia

  • decreased V/Q

CPAP

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treatment for arterial hypoxemia

  • intrapulmonary shunt

CPAP

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treatment for arterial hypoxemia

  • diffusion defect

steroids (?)

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treatment for arterial hypoxemia

  • decreased atmospheric pressure (PB)

lower altitude

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treatment for arterial hypoxemia

  • decreased FiO2 (<21%)

oxygen

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MV goals

  • allow pulmonary system to have an adequate level of alveolar ventilation

  • reduce WOB until cause of RF is treated

  • restore arterial and systemic acid-base balance to levels that are normal for patient

  • increase O2 delivery to tissues

  • prevent complications associated with MV

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possible alternatives to MV

  • supplemental O2 (ie, HFNC)

  • patient positioning (upright/Fowlers)

  • medications

  • resolve cause

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benefits of noninvasive positive pressure ventilation (NPPV)

  • treats acute-on-chronic RF unless CV instability is present

  • reduces need for intubation

  • reduces complications of ventilation

  • shortens hospital stay

  • reduces hospital mortality rates

  • benefits patients with ARF associated with cardiogenic pulmonary edema

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noninvasive ventilation (NIV)

  • indications

at least 2 factors present:

  • RR > 25 breaths/min

  • pH 7.25-7.30

  • PaCO2 45-60 mmHg

  • moderate-to-severe dyspnea with accessory muscle use and paradoxical breathing

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noninvasive ventilation (NIV)

  • absolute contraindications

  • respiratory arrest

  • cardiac arrest

  • CV instability

  • non-respiratory organ failure

  • patent tracheoesophageal fistula

  • inability to protect airway and/or high risk of aspiration

  • uncooperative patient

  • facial/head surgery or trauma

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noninvasive ventilation (NIV)

  • relative contraindications

  • copious/viscous secretions

  • fixed nasopharyngeal abnormalities

  • extreme obesity

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NIV to MV indications

  • respiratory arrest

  • RR > 35 breaths/min

  • severe dyspnea

  • PaO2 < 40 mmHg or PaO2/FiO2 < 200

  • pH < 7.25

  • PaCO2 > 60 mmHg

  • hyper-somnolence

  • impaired mental ability

  • CV complications

  • NIV failure