Critical Care Exam 2

breath sound associated with fluids; can sometimes “cough out”

crackles

breath sound associated with fluid in a larger airway, such as with pneumonia; deeper sound

rhonchi

breath sound associated with tertiary bronchi/airway constriction

wheezes

breath sound associated with airway narrowing; located in the upper airway

stridor

normal base excess range & what they mean

normal: -2 to +2; - = acidic, + = basic

7 steps of RSI

1. preparation

2. pre-oxygenation (min. of 2-3mins)

3. pre-treatment (narcotic, THEN sedative)

4. paralysis

5. positioning

6. placement of ETT (3-4cm above carina)

7. postintubation management

two vent settings associated with CO2

RR & tV

two vent settings associated with O2

FiO2 & PEEP

preset RR & tV; ALL breaths receive preset tV

V-A/C

tV, RR, PEEP, FiO2

preset RR, preset tV for ventilated breaths ONLY. tV of spontaneous breaths are pt dependent

V-IMV/S-IMV

tV, RR, PEEP, FiO2, PS

positive airway pressure during spontaneous expiration

CPAP

PEEP & FiO2

extra pressure delivered during spontaneous inspiration

PS mode

FiO2 & PS

pressure support & PEEP

BiPAP

PEEP, FiO2, PS

pressure limit set during BOTH ventilator and spontaneous inspiration; considered a lung protective mode

P-A/C

RR, PEEP, FiO2, PL

uses both pressure and volume control

hybrid modes (PRVC, APV-CMV)

tV, RR, PEEP, FiO2, PL

barotrauma

caused by excessive pressure in the alveoli (ex: too much PEEP)

volutrauma

caused by excessive volume in the alveoli (ex: too much tV)

sx of volu/barotauma

increased PIP, decreased lung sounds, tracheal shift, hypoxia, increased HR, decreased BP

sx of oxygen toxicity

substernal chest pain with deep breaths, dry cough, pleuritic pain

VAP bundle (7 things)

1. HOB 30-45 degrees

2. SAT daily

3. SBT daily (if pass SAT)

4. subglottic suctioning q6hr

5. DVT & peptic ulcer prophylaxis

6. oral hygiene q2hr

7. reposition ETT q4hr

VAP occurs ___ hours after intubation

24-72

fentanyl, hydromorphone, & morphine are used as ___ in the ICU setting

analgesics

propofol, lorazepam, midazolam, ketamine, and dexmedetomidine are used as ___ in the ICU setting

sedatives

cistracurium, vecuronium, and succinylcholine are used as ___ in the ICU setting

paralytics

considerations for:

• propofol

• lorazepam

• dexmedetomidine

• propofol: lowers BP

• lorazepam: affects kidneys

• dexmedetomidine: bradycardia

RASS goal (scale +4 to -5)

CPOT goal (scale 0-8)

TOF goal (scale 0/4-4/4)

RASS goal = +1 to -2

CPOT goal = <3

TOF goal = 2/4 twitches

criteria that must be met before starting a SAT

pt must be hemodynamically stable; Hgb >8, PEEP <5-8, SaO2 >90%, FiO2 <40%, mVe <15L/min

passes of a SBT

RR <35, HR <120, SBP >90 & <180, SaO2 >90%, FiO2 <40%, tV <4mL/kg; CO2 doesn’t increase by >10 & no agitation/diaphoresis/increased WOB

type 1 vs type 2 ALF

• type 1: hypoxia without a rise in CO2

• type 2: hypoxia & hypercapnia

intrapulmonary shunting

fluid in the alveoli prevent the alveoli from giving O2 to Hgb; can treat this with PEEP & abx if due to PA

diffusion defect

inflammation of the alveoli, thick wall prevents diffusion; can treat with steroids

V/Q mismatch & how to calculate

<1: respiratory issue, >1: cardiac issue

mVe (V) = RR x tV

CO (Q) = HR x SV

ARDS diagnosis criteria

noncardiogenic pulmonary edema, acute onset, bilateral infiltrates, decreased oxygenation

P:F ratio & what the values mean

PaO2/FiO2

• 200-300 = mild

• 100-200 = moderate

• <100 = severe

3 phases of ARDS

1. exudative

2. proliferative

3. fibrotic

sx of exudative phase

hypoxemia, low RR, increased WOB, increased resistance, decreased compliance, chest xray changes

• intrapulmonary shunting begins

sx of proliferative phase

improvement of symptoms OR worsening/no change of symptoms

sx of fibrotic phase

stiffening of the lungs (increased Ppeak) continued pulmonary HTN, refractory hypoxemia, bronchiole breath sounds over peripheral lungs

ARDS tx with ventilator

• low tV (4-6mL/kg)

• maintain airway pressure <30cm H2O

• permissive hypercapnia if on HIGH FiO2

• oxygen therapy with FiO2 & PEEP

• nontraditional vent modes - inverse ratio

• ECMO

benefits of prone positioning >12hr/day

• increased lung tissue recruitment

• decreased resistance

• increased compliance

• mobilizes secretions

• allows larger surface area of lungs to properly ventilate

BIS monitor & goal

used to monitor sedation in the paralyzed patient; goal of 40-60 (range 0-100)

100 means pt is fully awake