Professional Documents
Culture Documents
Ventilation - Always treat FIRST; a combination of PaCO2 and pH; ventilation when
respiratory acidosis < 7.30 pH; remember respiratory alkalosis is not a ventilation problem
Exceptions:
Severe COPD:- try BiPAP 1st b/c hard to wean from CMV
initiate IPAP~15 cwp with an EPAP~ 4 cwp (See: COPD normal ABG's)
NMD:- Respiratory Insufficiency (i.e.: RR >35 b/min., HR>100 b/min.
& even though N acid/base balance = intubate & CMV b/c impending AVF
Cerebral Trauma:- (i.e.: MVA, Sub-Arachnoid Hemorrhage) keep
PaCO2 = 25-30 Torr so pH is alkalotic to ICP (via vessel constriction) &
keep PaO2 ~ 100 Torr (i.e.: FIO2 as needed)
Oxygenation Always treat 2nd; after evaluating ABG for
Respiratory Alkalosis (Acute or Uncompensated) with Mod. Hypoxemia
FIO2 to 60% max., then start CPAP b/c refractory hypoxemia
Wean from FIO2 and CPAP (or PEEP) by FIO2 1st till reach 60 %, then
PEEP until = 5 cwp, and then FIO2 again in 10% increments to ~ 40-30%
b/c O2 toxicity is 1st concern and barotraumas is 2nd
Can MV if FIO2 and PEEP is not an option (i.e.: f, Vt, add PS) to PaO2
Tissue Hypoxia exists if PvO2 < 30 Torr & or SvO2 < 56 %
DC all O2 therapy if PaO2 = > 5 X FIO2 %
Supplemental O2 Adult ~ should be in range of 30% to 60% FIO2
NRB (100%) ~ indicated ONLY in emergency or trauma conditions
CMV - Weaning Parameters: weanable ifVC 1015 ml/kg IBW; measures for effective cough (monitor daily)
MIP -20 cwp; measures strength for effective cough (monitor daily); N= -50100cwp
Vt spont 3 ml/lb. or 6.6 ml/Kg of IBW indicates "continue weaning"
RSBI = RRspont./Vt spont.(L) ; # < 100 = weanable; # > 100 = needs CMV
(A-a)G on 100% < 350 Torr before weaning attempted; where N = 60100 Torr; b/c
>350 Torr V/Q mismatch or diffusion deficit [i.e.: (A-a)G should be ]
VD/Vt < 0.60 = pt ready to wean; where 25%35% (i.e.:0.25 0.35)= N
Where:
VD/Vt = PaCO2 - PECO2
and therefore
PaCO2
VD = PaCO2 - PECO2 X Vt
PaCO2
PEP > 40 cwp = weanable b/c effective cough (also: MEP, MEF)
Always choose MIP, VC, RRspon, Vt spon., when considering weaning, even if on A/C= 12
ETT Sizes - Adults:
Teenager (16 YO)
= 7.0 mm;
Female (average size)
= 7.5 8.0 mm;
Male
= 8.0 8.5 mm
Large Adult
= 9.0 10.0 mm
CMV - Weaning Strategy
Switch from A/C to SIMV where
f =10, 8, 6, 4 or 2 flow-by; after ABG results reveal respiratory alkalosis
without hypoxemia;
always adjust f (not Vt) to change Valveolar with SIMV or Control modes and
always adjust Vt (not f) to change Valveolar in A/C mode
consider PS of 512 cwp to WOB through ETT (or 510 cwp)
FIO2 to 60 %, then PEEP/CPAP to 5 cwp, then FIO2 until 4030 %
Make changes b/c of :
ABG results reveal respiratory alkalosis without hypoxemia
or b/c pt. is resting comfortably with good spontaneous ventilation
measurements
or b/c MIP & VC (done daily) are acceptable
Note: Small ventilator changes are better than big changes
Remember: Adjust f to alter PaCO2 in SIMV or Control modes AND
Adjust Vt to alter PaCO2 in A/C (where VE is best changed)
Auto-PEEP (intrinsic PEEP) - Monitor expiratory flow curves returning to zero;
causes risks of barotrauma & CO
ABG for Severe COPD; Normal values
PaO2 = 50 65 Torr
PaCO2 = 50 60 Torr or
pH
= 7.30 7.35
HCO3- 32 mEq/L
Note - COPD chemoreceptors not depressed until PaO2 ~ >70 Torr
IBW Calculation (NBRC)
female = 105 lb for 60" plus 5 lb/in. over 60"
male = 106 lb for 60" plus 6 lb/in. over 60"
Estimate VE, PaCO2, Vt or f, where:
f(Desired) X PaCO2 (Desired) = f(Actual) X PaCO2 (Actual)
and therefore the following can be formulated:
fdesired = (f current) (PaCO2 current)/ PaCO2 desired ; where ()() = ()() or ()()=()()
.
.
VE desired = (VE current)(PaCO2 current) , Also
PaCO2 desired
Neonatal Rules
(3,000 g or 3 Kg is normal birth wt. ~ 6.6 lbs.; anything less is probably a premie)
Initial Ventilator Settings for babies; Switch baby to PCV from CPAP after:
CPAP = 8 10 on 80% with PaO2 < 50 Torr and PaCO2 > 60 Torr (see neonate N ABG below)
Pressure Control for neonates with
f = 40 breaths per min.(or in range 3050 b/min.)
where normal RR = 4060 b/m
PIP = 25 cwp (or in range 1525 cwp)
FIO2 = 0.60 (b/c baby was on CPAP at 0.60)
PEEP = 2 4 cwp (only after initial therapeutic setting of 45cwp)
*Note - when PEEP, Vt will b/c of PC mode (i.e.: Vt=PIP-PEEP)
HFV = 3 types
1) HFPPV: where f = 60100/min., Vt = 35 ml/Kg, I:E = 1:3 or <
2) HFJV: where f = 100600/min., PIP ~ 810 cwp, I:E = 1:11:4
Alarms: PLow
3) HFO: where f = 603,600/min., Vt < VD anatomic
Also:
ECMO is indicated for those infants not responding to PC ventilation
Surfactant replacement is indicated for infants with RDS to open
up atelectatic alveoli; given within 1224 hours of 1st symptoms
Ventilator Changes for Neonates
Ventilation - Always treat first; a combination of PaCO2 and pH
Oxygenation Always treat 2nd a combination of FIO2 and PEEP
PEEP by only 24 cwp at a time
Caution with PPHN (Persistent Pul. Hypertension Neonate) b/c compressed
alveolar capillaries patent ductus arteriosis & or Foramen Ovale
FIO2 = 0.10 max. at a time, unless option exists to:
Titrate FIO2 to maintain SpO2 93%
Extubate when CPAP is @ 2 cwp (b/c normal FRC is maintained with CPAP = 2 cwp)
Apgar Scores: 5 parameters @ 0, 1 & 2 pts with 10 pts max.
710 = N = observe, sx upper awy w bulb syr., place in warmer
4 6 = moderate asphyxia = BVM stimulate & place on O2
0 3 = severe asphyxia = immediate resuscitation, ventilation with FIO2
ABG for Neonates:
PaO2 = 50 70 mmHg
PaCO2 = 35 45 mmHg
pH
= (7.25) 7.35 7.45
HCO3- = 2026
where, ROP (retinopathy of prematurity) ~ PaO2 > 80 Torr
also, Umbilical ABG = Radial ABG
Capillary Gases for Neonates:
PcO2 = 4050 Torr
PcCO2 = 4050 Torr
N Vital Signs for Neonates:
HR = 130-150 b/min., BP = 75/45 (9060/6030); RR = 4060 b/min.
acrocyanosis (peripheral cyanosis) is N after birth;
however, central cyanosis is NOT Normal and O2 trx must be initiated
Serum Glucose Levels should be measured in INFANTS
CBC should be assessed for O2 carrying capacity of the blood & infection
Ductus Arteriosus detected via two PTCO2 electrodes i) R upper chest (preductal) &
ii) L chest, abdn, or thigh (post ductal)
CPAP for Neonates:
Start CPAP ONLY when pt demonstrates hypoxemia on 60 % FIO2 (indicates atelectasis)
Remove ETT when CPAP = 2 cwp b/c < will FRC below N
CPAPmax. Neonates = 12 cwp (Sills p. 402)
ETT Sizes (neonates): 3,000 g or 3.0 Kg is normal birth wt.; anything less is probably a premie)
Pre-Term 2.5 Kg
= 2.5 mm;
Full Term (3840 wks gestational) = 3.0 mm;
1 year old
= 4.0 mm
CSE- DO NOT ORDER ON INFANTS - PEFR, MIP, VC as inappropriate
EKG
Recommend 12-lead ECG = to dx. signs/symptoms of acute serious cardiac arrhythmia
Atrial Fibrillation = Cardioversion is indicated; energy level = 25100 joules
Ventricular Fibrillation (also: Pulseless Ventricular Tachycardia) = Defibrillation is indicated;
200 J initially, then energy to 360 Joules if 2nd or 3rd is not successful.
All other cardiac arrhythmias are trxed w medication
Medication vs. Cardiac conditions:
Lidocaine - trx. Ventricular Fibrillation, Ventricular Tachycardia & PVCs
Epinephrine - trx. Ventricular Fibrillation, Sinus Arrest & Asystole
Atropine - trx. Sinus Bradycardia & Asystole
HR measured via EKG grid lines as: 300 (60/0.2), 150, 100, 75, 60, 50 (6th box or 60/1.2)
Equipment Rules
Flow Conversion to L/sec:
P(a-ET)CO2 = 15 Torr
P(a-ET)CO2> N or is indicates Pulmonary Emboli, LHF or COPD
Also: exhaling to END Max Exhalation can differentiate PE above: i.e.
P(a-RV)CO2> N = PE where P(a-RV)CO2= N indicates LHF or COPD
Transcutaneous O2 Analyzers PTCCO2 zeroed on RA: think Perfusion & Diffusion
IS - min VC => 10 ml/kg otherwise chg to IPPB
UAC ~ distal tip @ T6 T10; b/c lower causes cyanosis of lower extremities
CPT with head ~ if not tolerated add 10% FIO2 or change to PEP Device
NO (nitric oxide) is adm @ 10 ppm initially & to 20 ppm, where PVR>240 dynes.sec.cm-5
Reminder: PVR = N = 1.5 3.0 Torr or 80 - 240 dynesseccm-5
SPAG - set the nebulizer as high as it will go, then add enough drying flow to =
15 L/min total; also, drying chamber should have < 10 L/min. or no aerosol
Oropharyngeal Awy - used ONLY for unconscious pt. to maintain patent upper airway.
Combitube (ETC: Esophageal Tracheal Combitube) - an emergency awy device
inserted with minimal skill; not used with pediatric nor short adult pt.s;
use a colorimeter or capnography to determine where the tube is placed
Chest Tubes:
placed in 2nd 4th anterior intercostal space to evacuate air
placed in 6th 8th intercostal space to evacuate fluid
vacuum set at -20 cwp for Pleur-Evac System, or at
-15 cwp for direct line suction (b/c of < sx control)
Galvanic Fuel Cell recalibrate before replacing fuel cell, if FIO2 measurement a problem
LMA Laryngeal Mask Airway:
- inserted by minimally skill or perhaps an anesthesiologist during surgery (vs. ETT)
- lubricate posterior mask; insert with the index finger over epiglottis f/b
mask inflated 60 cwp
- can NOT be used on conscious nor semiconscious pts (b/c of gag reflex)
(must be unconscious)
- gastric distention = bagging or CMV where PIP > 20 cwp b/c LMA will leak
- aspiration can still occur
Pulse Oximeters
think Perfusion & shine a Light through the blood
Hemodynamics
Lab Data
Air bubble - should be suspected in an ABG when PO2 + PCO2 > 140 Torr on RA
Sputum:
Green ~ pseudomonas (foul smelling)
Yellow ~ WBC's or staph
Color vs. disease:
Pathology:
PFT Rules:
Interpretation of Results
# > 15% = significant response (improvement) to bronchodilator
mild, moderate and severe
Inspiratory flow = N = 2530 L/m
When interpreting PFT results, look at the choices~ 3 incorrect choices will type a
wrong pathology (i.e.: restrictive vs. obstructive). Choose the other single type.
MVV - performed for 5 -12 sec only (Sills); 10, 12, 15 sec's (Persing); @70-120 bpm
Geisler Tube Ionizer- a nitrogen analyzer used to measure ing exhaled N2 during
inspiration of 100% O2 for the determination of RV, FRC and TLC\
However, use helium washout with COPD pts b/c 100% O2 not used
Physiology Calculations:
Alveolar-Air Equation
PAO2 = (PB - PH2O)FIO2 - PaCO2(1.25); simplify where
shortcut
PAO2 = (7)O2% - PaCO2 + 10
i.e.: PB = 747, FIO2 = 50 and PaCO2 = 35
= (7 X 50) - (35+10) = 350 - 45 = 305 Torr
Desired FIO2 ; where FIO2 = PaO2 therefore divide; i.e.: where FIO2/PaO2 = 1; or
Desired FIO2 = Actual FIO2
Desired PaO2 Actual PaO2
simplified
Desired FIO2 = (Desired PaO2) X (Actual FIO2)
Actual PaO2
Also via math: where ()() = ()() or ()()= ()()
Bubble in ABG if:PaO2 + PaCO2 > 140 Torr on RA; {should be < or = with (A-a)G}
Dead Space:
Anatomic normal: VD anatomic = 1 ml/lb. IBW = 2.2 ml/kg IBW
Intubated Pt.: VD Intubation = 0.5 ml/lb. IBW = 1 ml/kg IBW
M(lb./Kg) F(lb./Kg)
106/48
118/54
130/59
142/65
154/70
166/76
178/81
105/48
115/52
125/57
135/61
145/66
155/71
165/75
Heimlich Maneuver- performed 1st during choking (do not clap on pts. back)
Urine output and color if a trauma patient b/c can demonstrate internal bleeding
Peripheral Pulses Only if cardiac pt. & to evaluate foot perfusion (dorsalis pedis)