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CPAP is the maintenance of:
positive pressure throughout the whole respiratory cycle (inspiration and
expiration), when breathing spontaneously
indications for CPAP:
- Sleep apnea
- Being weened from PEEP to obtain re-opening of atelectasis
- Hypoxic following extubation
- Hypoxic but not exhausted
Pressure for CPAP:
- 1 set pressure (cm H2O)
- 5-20 cm H2O
BIPAP is the maintenance of:
set positive pressure during inspiration and a lower set pressure during exhalation
- higher pressure- insp
- lower pressure- exhale
Benefits of BIPAP:
- Maintains patency of airways and alveoli
- Improves gas exchange
- Improves delivery of bronchodilators
- Moves extracellular fluid into vasculature
- Reduces work of breathing
indications for BIPAP:
- Non-tolerance of CPAP
- COPD exacerbation
- Respiratory failure--hypercapnea and hypoxemia
- Hypoxic following extubation
Pressure for BIPAP:
to improve ventilation:
to improve oxygenation:
- IPAP: 10-20 cm H2O
- EPAP: 5-10 cm H2O
- to improve ventilation: IPAP- blow off CO2
- to improve oxygenation: EPAP
when using PAP, what occurs during inspiration:
what occurs in the alveoli?
- IPAP forces air into the lungs, therefore, less work is required from the respiratory muscles
- this decreases the work of breathing
- The alveoli and bronchioles are prevented from collapsing at the end
of expiration = less pressure needed to re-expand them.
CI for CPAP/BIPAP:
- 1. Recurrent pneumothoraces / untreated pneumothorax
- 2. Severe post-operative pulmonary air leak
- 3. Central Apnea
- 4. Vomiting/Secretions
- 5. Any condition where an elevated Intracranial Pressure is undesirable or
where reduction in cerebral blood flow is inappropriate
- 6. Any situation where there is already significant lung over-distension
- 7. Unstable facial fractures, extensive facial surgery or lacerations and facial
- 8. Laryngeal trauma, recent tracheal anastamosis
- 9. Recent ear, nose and throat surgery
- 10. Inability to maintain their own airway
- Inadequate ventilation/oxygenation
- Nasal dryness
- Rhinorrhea (runny nose)
- Chest discomfort
- Induced central apnea
- Conjuctivitis (eye infection)
- Skin rash
- Pressure sores
Which PAP needs to be higher?
IPAP or EPAP
IPAP needs to be HIGHER than EPAP
what is a good PAP starting ratio?
what do you do if no improvement in O2?
what do you do if no improvement in CO2?
why do you need a good ratio btwn IPAP and EPAP?
- a good ratio allows for exhalation
- a poor ratio can cause air trapping
- want 4 or 5 gradient btwn IPAP and EPAP
indications for mechanical ventilation?
- Failure to adequately ventilate
- Failure to adequately oxygenate
what are some concerning findings with mechanical ventilation?
- Respiratory rate > 35/min or less than 6/min
- Inability to maintain arterial O2 saturation > 90% with fractional
inspired O2 (Fio2) > 0.60
- PaCO2 > 55 mm Hg with pH < 7.25
- Vital capacity < 15 ml/kg in adults and 10 ml/kg in children
why is it imp to look at pH when looking at PaCO2?
- bc a low PaCO2 could be their norm. The pH tells you whether or not the body is compensating
- (good or bad)
regardless of patient's own inspiratory efforts
ASSIST-CONTROLVENTILATION (A/C) OR CONTINUOUS
MANDATORY VENTILATION (CMV):
pressure in response to the patient's inspiratory effort, but will initiate the breath if the patient does not do so within a preset amount of time
Pressure Regulated Volume Controlled (PRVC)-
- a form of A/C, breaths can be ventilator or patient initiated.
- A constant pressure is applied throughout inspiration.
- Ventilator adjusts pressure from breath to breath to deliver a set tidal volume
SYNCHRONOUSINTERMITTENT MANDATORY VENTILATION
- delivers the preset volume and preset respiratory rate while allowing the patient to breathe spontaneously.
- The vent initiates each breath in synchrony with the patient's breaths
POSITIVE-ENDEXPIRATORY PRESSURE (PEEP)
- Same as EPAP.
- positive pressure that is applied by the ventilator at the end of expiration
PRESSURE SUPPORT VENTILATION (PSV):
- preset pressure which augments the patient's spontaneous inspiration effort and decreases the work of breathing
- (makes sure the pt reaches a certain pressure before exhaling)
HIGHFREQUENCY VENTILATION (HFV):
- delivers a small amount
of gas at a rapid rate (as much as 60-100breaths per minute)
- not used very much
TV + RR=
- Minute ventilation
- which effects CO2 level
FiO2 and PEEP effect:
imp ventilator setting that you will include in your vent order:
- PSV (if appropriate)
- Sensitivity (effort required for pt to take breath)
- I Time ( inspir phase in sec's)
- Pressure limit (top pressure during inspir)
ventilator settings to improve oxygenation (O2):
ventilator settings to improve ventilation (CO2):