Mechanical Ventilation

Q: What are the indications for Mechanical Ventilation A: 1) PO2 50 mmHg or < 2) O2 sats 90% or < inspite of O2 concentration of 60% 3) PCO2 > 50 4) pH < 7.3 Q: Indications for intubation in pt with neuro-muscular disease? A: VC < 15 cc/kg and MIP < 20 cm H2O.

Assist control ventilator delivers breath when triggered by pt or independent of it, you see
set tidal volume and backup rate. Q: AC vent TV 600, RR 12, pt is breathing RR 16. How many breaths will vent give out? A: 16@ 600 tv. Pt triggers 16 breaths but has fixed TV. Q: AC vent TV 600, RR 12, pt is breathing RR 10. How many breaths will vent give out? A: Vent give 12 breaths @ 600 TV.

IMV pt receives periodic + pressure breaths at pre-set volume and rate, spontaneous
breathing is allowed. Q: Pts IMV vent TV 1000, RR 6. Pt breathing at 16 breaths/min. How many breaths will vent deliver? A: Vent will give 6 breaths of 1000 TV. Pt will take an additional 10 breaths on his own.

PS - has set level of pressure. No volume. It is entirely patient triggered. Non-invasive

ventilation includes bipap and cpap. Q: How to measure PEEP? A: By occluding airway @ end-expiration. It measures Plateau pressure. By doing this it will cause BP to decr, HR to incr, Venous Return to decr, JVP to incr. Difference b/w peak and plateau = airway resistance. Q: What is the treatment of Auto-peep? A: 1) increase inspiratory flow rate and decr I:E 2) decrease minute ventilation ( decr TV or RR) 3) bronchodilators 4) IV fluids Q: What is the most common cause if BP decreases after mechanical ventilation and WTD? A: Auto-Peep. D/C ventilator and use ambu-bag. Then decrease minute ventilation. Q: Pt on vent with decreased BP and Increased frequency of pressure alarm with each breath. PK pressure 60, PL 58. Dx? A: Tension pneumothorax. Place large bore needle into 2nd pleural space and then place chest tube. In a tension pneumothorax, the trachea shifts. Q: pt with COPD on respirator for > 48 hours has been stable, suddenly becomes restless, BP decr, HR incr, and decreased breath sounds on right, peak pressure 60 and plat pressure is 40. Dx? A; Mucous plugging. Q: Pt on vent pH 7.25 and PCO2 60. How to normalize pH?

A: Increase Minute Ventilation ( increase tv or rr). Q: Pt with PCO2 28, pH 7.55, PO2 80. How to raise PCO2? A: Decrease minute ventilation. Q: Pt on ventilator with ARDS, TV 800, RR 12, FiO2 60%. In order to lower FiO2, PEEP is added. After 1 hour, pt develops decreased BP, Increased HR, decreased urine output. Dx? A: Physician inflicted PEEP Q: Pt with drug overdose is on the vent, PCO2 60, PO2 54, pH 5.25. Peak airway pressure decreases from 30 to 8. Low pressure alarm triggers. Dx? A: endotracheal tube cuff leak. Q: ARDS pt on PEEP 10, FiO2 60%, PO2 80. What should be lowered first. PEEP or FIO2? A: FIO2. Q: Best way to monitor O2 in pt in shock? A: measure mixed veonous O2. Weaning from respirator. - Do once daily trials - First do 3 minute T-piece trial. At the end of 3 min,if TV > 5cc/kg, RR < 35, MIP - 20 cc. Then proceed with trial. - Extubate if pt can tolerate 30 minuets of spontaneous breathing. Q: pt intubated for respirator failure after intubation, pt becomes hypotensive, decrease breath sounds on left side. Dx? A; Right main stem bronchus intubation. Rx by pulling tube out and repositioning. Q: Pt with COPD, intubated on vent, then SBP 140 decreases to 100, end-expiratory pressure = 0. Therefore no autopeep. Dx? A: Hypotension secondary to hypovolemia. Rx with fluids (+pressure decreases preload-> Blood pressure decreases).

PFTs
Spirometry cant measure residual volume. It can measure FEV1. In expiration, maximum airflow is in the beginning. Approach to PFTs. o Look for normals. Everything 80% is normal. o Look for restrictive disease = TLC < 80%, FEV1/FVC > 80% but FVC < 80%

If restrictive look for DLCO. If decrease in DLCO is proportional to decrease in TLC -> due to extrathoraic cause not parenchymal. Eg: obesity and kyphosis

o Look for obstructive disease = FEV1/FVC < 80% Check TLC, DLCO and reaction to beta 2 agonist. Emphysema has increased TLC, low DLCO, - rxn to beta agonist Asthma = nl DLCO or + rxn to beta agonist. Sarcoidosis (restricve +/- obstructive pattern), eosinophilic granuloma, lymphanioleiomyomatosis.

o Others are combinations of obstructive and restrictive diseases

o Obstructive diseases: decr FEV1, Decr FVC, FEV1/FVC < 0.8, nl or incr TLC, incr RV, nl or decr DLCO, MIP and MEP are nl. o Restrictive Diseases: decr FEV1, decr FVC, FEV1/FVC > 0.8, decr TLC, decr RV, MIP and MEP are nl. o DLCO is decreased in lung parenchymal diseases.

A-a gradient = [(713x02%)-PCO2 x 1.25)] - PaO2.

PAO2-PaO2= 5-15 mm Hg

o Room Air = [150-PCO2(1.25)] -PaO2 o Normal A-a gradient is < 15 for those under age 30 and increases by 3 Q10 years. Q: 52 yo smoker with exertional dyspnea, b/l rales, +cxr showing chronic changes, PFT: FVC 60%, FEV1 51%, FEV1/FVC 0.8, RV 60%, DLCO 40%, MIP and MEP are WNL. A: Parencymal interstitial restrictive disease. FEV1/FVC 0.8 (restrictive) and DLCO was decreased significantly (Parenchymal disease). MIP and MEP are nl (not neuromuscular)

Hypoxia/Oxygen therapy
Q: COPD pt with hypoxia after O2 therapy, his Po2 increases. What is the cause? A: V-Q mismatch. In shunting-> PO2 does not increase with supplemental O2. -Pt started on O2 should be evaluated in 1-3 months with repeat blood gases for continuing O2. If values are still low, then needs O2 indefinitely. -Duration of O2 -> 24hours/day -Goal = PO2 60-65, O2 sats 90-92%. With O2 to deliver 1-2L/min. -Initial determinant of O2 = ABG, and additional adjustment is based on the O2 sat. Q: 60 yo male with CAP, PaO2 52, no increase in PaO2 with supplemental O2. Cause? A: Shunting. Shunting may increase if pt lies on the side of the pneumonia (PO2 will drop secondary to shunting). Q: 26 yo male with dyspnea of few hours had dental filling by dentist a few hours ago. CXR is negative. PO2 86 and arterial blood appears brown. Dx? A: Methemoglobinemia caused by benzocaine used during procedure. Benzos, dapsone, and nitrates can cause this.

Q: Hypoxic patient with trachea shifting toward side of the lesion. Dx? A: Fibrosis or atelectasis. Q: Pt with COPD, PO2 62, PCO2 40, no complaints, poor exercise performance? WTD? A: Measure O2 sat during exercise. If 88% or < during exercise, then give portable O2. Q: What are complications secondary to hypoxia? A: 1) Increased HCT 2) Pulmonary HTN 3) Daytime somnolence 4) cardiac arrthymias. Q: COPD pt, PO2 64 wants to undertake air travel? WTD? A: Indications for O2 = resting PO2 70 or <. You must call airline to arrange for it. If already on O2 increase flow rate by 1-2l/min. Q: 36 yo smoker with emphysema and bibasilar bullae on cxr. WTD? A: test for alpha 1 anti-trypsin levels. - In homozygous - levels 10-15 < Normal -> Need replacement - In hetereozygous - levels 10-15% < Normal -> No rx necessary. - There is and increased risk of cirrhosis and HCC. Q: 70 yo female with exertional dyspnea, hx of smoking, PO2 64, What test to do Next? A: PFTs to diagnose COPD. Severity can be judge by FEV1: o Stage II FEV 1 > 50% o Stage III FEV1 35-49% o Stage IV FEV1 < 35%