Guide to the nbrc hospital

Revised: Oct. 13, 2008

PaCO₂ with pH < 7.30 (Hypercarbia with Respiratory Acidemia)

Use only 10 ml/Kg V_t for child

For exacerbation of Severe COPD try-

1^st: V/M @ 28% or 2 L/m N/C if V/M not an option; but avoid N/C b/c

delivery is estm.

2^nd: BiPAP - if pH is < 7.30 (see: N COPD ABG)

where IPAP adjusts ventilation (1015 cwp)~ V_t with pH

and EPAP adjusts oxygenation (4 cwp) ~ P_aO₂

3^rd: CMV with smaller V_t & F_IO₂ initial parameters or

If fails, switch to SIMV with PS

intrinsic PEEP or auto-PEEP

b/c of chemical mediator release lung damage (ALI= acute lung injury)

Initial PCV settings;

PIP_PCV estm. = at 50% of PIP_A/C (on A/C) or = P_plat, then

target V_t by adj. PIP_PCV where 5  7 ml/Kg _IBW

(See Permissive Hypercapnea above) and add

F_IO₂ = 100% or 1.0

I:E = 1:2 or inverse ratio with pt. sedation; caution

2:1 ratios or > b/c Auto- PEEP can occur

Monitor V_{t Exh.} b/c PIP limit determines V_t: C_L or R_aw changes affect V_{t Exh}

PCV also indicated in pleural air leak where

set PIP_PCV = P_Plateau adjusting f to control PaCO₂
For NMD with fatigued muscles and stable C_st - use Bilevel ventilation


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:

initiate IPAP~15 cwp with an EPAP~ 4 cwp (See: COPD normal ABG's)

& even though N acid/base balance = intubate & CMV b/c impending AVF

keep PaO₂ ~ 100 Torr (i.e.:  F_IO₂ as needed)

Wean from F_IO₂ and CPAP (or PEEP) by F_IO₂ 1st till reach 60 %, then

PEEP until = 5 cwp, and then F_IO₂ again in 10% increments to ~ 40-30%

b/c O₂ toxicity is 1st concern and barotraumas is 2nd

>350 Torr  V/Q mismatch or diffusion deficit [i.e.: (A-a)G should be ]

Where: V_D/V_t = PaCO₂ - P_ECO₂ and therefore

PaCO₂

V_D = PaCO₂ - P_ECO₂ X V_t

PaCO₂

Switch from A/C to SIMV where

always adjust f (not V_t) to change V_alveolar with SIMV or Control modes and

always adjust V_t (not f) to change V_alveolar in A/C mode

consider PS of 512 cwp to  WOB through ETT (or 510 cwp)

F_IO₂ to 60 %, then PEEP/CPAP to 5 cwp, then F_IO₂ until 4030 %

Make changes b/c of :

ABG results reveal respiratory alkalosis without hypoxemia

or b/c pt. is resting comfortably with good spontaneous ventilation

measurements

Note: Small ventilator changes are better than big changes

Remember: Adjust f to alter P_aCO₂ in SIMV or Control modes AND

Adjust Vt to alter P_aCO₂ in A/C (where V_E is best changed)

Auto-PEEP (intrinsic PEEP) - Monitor expiratory flow curves returning to zero;

causes risks of barotrauma & CO

Note - COPD chemoreceptors not depressed until PaO2 ~ >70 Torr

female = 105 lb for 60" plus 5 lb/in. over 60"

male = 106 lb for 60" plus 6 lb/in. over 60"
Estimate V_E, PaCO₂, V_t or f, where:

f_(Desired) X PaCO_{2 (Desired)} = f_(Actual) X PaCO_{2 (Actual)}

and therefore the following can be formulated:

f_desired = (f _current) (P_aCO_{2 current})/ PaCO_{2 desired} ; where (↑)(↓) = (↓)(↑) or (↓)(↑)=(↑)(↓)

. .

V_{E desired} = (V_{E current})(PaCO_{2 current}) , Also

PaCO_{2 desired}

V_{t desired} = (V_{E current})(PaCO_{2 current})

PaCO_{2 desired}
Neonatal Rules

(3,000 g or 3 Kg is normal birth wt. ~ 6.6 lbs.; anything less is probably a premie)

where normal RR = 4060 b/m

*Note - when PEEP, V_t will  b/c of PC mode (i.e.: V_t=PIP-PEEP)

HFV = 3 types

1. 
   HFPPV: where f = 60100/min., V_t = 35 ml/Kg, I:E = 1:3 or <
   
2. 
   HFJV: where f = 100600/min., PIP ~ 810 cwp, I:E = 1:11:4
   

3. 
   HFO: where f = 603,600/min., V_t < V_{D anatomic}
   

up atelectatic alveoli; given within 1224 hours of 1st symptoms

Caution with PPHN (Persistent Pul. Hypertension Neonate) b/c compressed

alveolar capillaries  patent ductus arteriosis & or Foramen Ovale
 F_IO₂ = 0.10 max. at a time, unless option exists to:

Titrate F_IO₂ to maintain S_pO₂  93%

710 = 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 F_IO₂

where, ROP (retinopathy of prematurity) ~ P_aO₂ > 80 Torr

also, Umbilical ABG = Radial ABG

Capillary Gases for Neonates:

P_cO₂ = 4050 Torr

P_cCO₂ = 4050 Torr
N Vital Signs for Neonates:

HR = 130-150 b/min., BP = 75/45 (9060/6030); RR = 4060 b/min.
acrocyanosis (peripheral cyanosis) is N after birth;

however, central cyanosis is NOT Normal and O₂ trx must be initiated

ii) L chest, abdn, or thigh (post ductal)

Start CPAP ONLY when pt demonstrates hypoxemia on 60 % F_IO₂ (indicates atelectasis)

Remove ETT when CPAP = 2 cwp b/c < will ↓ FRC below N

CPAP_{max. Neonates} = 12 cwp (Sills p. 402)

Recommend 12-lead ECG = to dx. signs/symptoms of acute serious cardiac arrhythmia

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:

HR measured via EKG grid lines as: 300 (60/0.2), 150, 100, 75, 60, 50 (6^{th box} or 60/1.2)

Flow Conversion to L/sec: 60 L/min = 1.0 L/sec

50 L/min = 0.83 L/sec

45 L/min = 0.75 L/sec

40 L/min = 0.67 L/sec

30 L/min = 0.50 L/sec

5 L/min = 0.0833 L/s; i.e.: 20 L/m = 4(0.08333) = 0.33 L/s
Air:Oxygen Ratios: 60% = 1:1

50% = 5:3

45% = 2:1

40% = 3:1

35% = 5:1

30% = 8:1

28%= 10:1

26%= 15:1

24% = 25:1

Heliox:

ONLY delivered via NRM

shortcuts = multiply O₂ flowmeter rate by 2 & round  to estm. He/O₂ flow

= divide He/O₂ Rx by 2 & round ­ for O₂ flowmeter flow to use

70/30 mixture = 1.6 X O₂ flow = actual flow_Heliox

shortcuts = multiply O₂ flowmeter by 1.5 & round ­ estm. He/O₂ flow

= divide He/O₂ Rx by 1.5 & rd ­ for O₂ flowmeter flow to use

70/30 is lowest He concentration delivered b/c O₂ is heavy

1 lb LOX = 344 L gaseous O₂

1 L LOX = 2.5 lb LOX = 860 L gaseous O₂
Cylinder to Empty

Textbook calculation # min = (# psig)X[(0.28~E; 3.14~H )]

# L/min

# min = # hours

60 min/hr.

Billy Bob's Shortcut:

* for E cylinder ~ substitute 0.28 to 0.3

* drop one zero from the # psig and multiply by 3

* divide by # L/m, which ~ # min

* drop the last digit and divide by 6, ~ # hours

* choose the # min or hours that is slightly lower than calculated

* for H cylinder: substitute 3 for 3.14 and round up
Capnography - N exhaled air contains CO₂ = 4.55.5% or 3545 Torr

If ETT is in the esophagus, then this value will be near zero % (i.e.: 0.5%)

Note: PaCO₂ > P_ETCO₂ and

P_(a-ET)CO₂ + P_ETCO₂ estimates PaCO₂ also

P_(a-ET)CO₂ = 15 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

Reminder: PVR = N = 1.5  3.0 Torr or 80 - 240 dynes∙sec∙cm^-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 2^nd  4^th anterior intercostal space to evacuate air

placed in 6^th  8^th 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 F_IO₂ 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

PAP when PVR or PCWP; then CVP also 

also PAP b/c of PaCO₂, pH, or PaO₂, hypervolemia (start Lasix)

PAP b/c hypovolemia (add fluids), pul. vasodilation, or PaO₂

PCWP = left heart abn.s (i.e.: CHF, Mitral & Aortic Valve Stenosis)

PCWP > 18 Torr b/c of "Cardiogenic PE" from CHF (LHF)

Also, increased b/c aortic stenosis, mitral valve regurgitation)

PCWP < 4 Torr = hypovolemia;

NOTE: PE with N PCWP indicates "Noncardiogenic PE" (i.e.: ARDS);

Balloon tip inflation hold for < 1520 sec. to prevent infarction

PVR = N = 1.5  3.0 Torr or 80 - 240 dynes∙sec∙cm^-5

if PVR = pulmonary hypertension (b/c of acidemia, hypercapnia, hypoxia, then PAP)

then CVP & PAP are also 
SVR (Systemic Vascular Resistance) = N = 900 - 1400 dynes∙sec∙cm^-5;

SVR < 900 ~ hypovolemia;

SVR > 1400 ~ hypervolemia
Tissue Hypoxia = S_vO₂ < 56% & or = P _vO₂ < 30 Torr: where N. P _vO₂ = 40 Torr (3743)
CI =Cardiac Index =Q_T/BSA  N Q_T = 2.54.0 L/min/sm²of body surface area

= a reflection of Q_T (cardiac output)

CI < 2.5 ~ hypovolemia;

CI > 4.0 ~ hypervolemia

[C_(a-v)O₂] X 10 where VO₂ = O₂ consumption

N = 4  6 vol% or where > 6 ~ CO (maybe trx w fluid intake)

and < 4 ~ CO (septic shock or anemia may be indicated)
If P_vO₂ after PEEP, then Q_T demonstrated; therefore PEEP to previous level
RQ = V/Q = 4.2/5.0 = 0.8 = N
Lab Data       

Air bubble - should be suspected in an ABG when PO2 + PCO2 > 140 Torr on RA

Sputum:

Yellow ~  WBC's or staph

Color vs. disease:

CB = viscous yellow or green

CF = viscous yellow or green

PE = Pink & frothy

Asthma without infection = Clear, white

Electrolytes:

Na⁺ = 135  145 mEq/L; ~ 140; Na⁺ = muscle weakness & difficult vent weaning

K⁺ = 3.5  5.0 mEq/L; ~ 4; K⁺ = muscle weakness & AVF; cardiac arrhythmias &

flatted "T" wave; difficult vent. Weaning

Umbilical ABG = Radial ABG

Cardiac Enzymes - Lab blood test run to determine if MI occurred

BUN ~ blood/urea/nitrogen =  in renal failure

HbCO measurement is an effective test for smoking cessation program noncompliance

 BS on a lateral side, asymmetrical chest movement, tracheal movement away from mid-

line; Trx - insert Lg bore needle/rubber catheter into 2nd (between 2&3) intercostal space.
Severe COPD - typical ABG's

P_aO₂ = 50 - 65 Torr (chemoreceptors are activated in this range)

P_aCO₂ = 50 to 60 Torr (respiratory acidosis)

pH = 7.30 - 7.35; (partly compensated respiratory acidosis)

HCO3- = 34 - 37 mEq/L (metabolic alkalosis compensation)

Note - chemoreceptors not depressed until PaO₂ ~ >70 Torr

intrathoracic pressure, atelectasis, P_(A-a)G & oxygenation

Flat sound - over areas of sternum, muscles, atelectasis (tissue or bone)

Dull sound - over areas that are fluid filled (heart, liver, pleural effusion, pneumonia)

Resonant – normal

Hyperresonant – over hyperinflated areas i.e. COPD, Status Asthmaticus
Palpation ~ to touch for, or listen to:

Abnormalities of anatomy or areas of tenderness: ie.: tracheal shift, fractured ribs

Tactile fremitus – “99” is spoken with changes in vibrations felt

Vocal fremitus – 99’ is spoken with normal air muffling heard via stethoscope

when IS not tolerated

Interpretation of Results

# > 15% = significant response (improvement) to bronchodilator

mild, moderate and severe

wrong pathology (i.e.: restrictive vs. obstructive). Choose the other single type.

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

P_AO₂ = (P_B - P_H2O)F_IO₂ - PaCO₂(1.25); simplify where

P_AO₂ = (7)O₂% - PaCO₂ + 10

= (7 X 50) - (35+10) = 350 - 45 = 305 Torr

Desired PaO₂ Actual PaO₂ simplified

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: V_{D anatomic} = 1 ml/lb. _IBW = 2.2 ml/kg _IBW

Intubated Pt.: V_{D Intubation} = 0.5 ml/lb. _IBW = 1 ml/kg _IBW
↑V_D = ↑ PaCO₂ (i.e.: pulmonary emboli)
Capillary Refill = N = or < 3 sec.; If

> 3 sec. = indicates ↓perfusion, hypotension or a cold extremity

Where N = 15  20 vol % (NO REFERENCE)

5'0" 106/48 105/48

5'2" 118/54 115/52

5'4" 130/59 125/57

5'6" 142/65 135/61

5'8" 154/70 145/66

5'10" 166/76 155/71

6' 178/81 165/75

50 L/min = 0.83 L/sec

40 L/min = 0.67 L/sec

30 L/min = 0.5 L/s

N_ventilator = 6070 ml/cwp

P_plat - PEEP

PIP - PEEP

N_nonintubated = 0.6 2.4 cwp/L/s;

N_intubated = 5 cwp/L/s

NBT_sat = 47 mmHg (P_H2O) = 44 mg _H2O/L_gas

CF; also: can  bronchospasms

bronchospasm (see cardiac conditions below) and

- also adm for ventricular arrhythmias via IV or ETT if IV not available

Sedate & Paralyze is most efficient method of treating combative pt on CMV

Valium (diazepam) - a sedative commonly administered during a bronchoscopy\

(a short acting antianxiety med.)

(a short acting barbiturate)

paralysis X 5', 2 mg (should add sedative)

pancuronium (Pavulon)- paralysis while on CMV; reversed with Tensilon (neostigmine)

nitroprusside sodium (Nipride)- a potent fast-acting peripheral vasodilator to BP(hypertension)

Inderal - adm to BP (hypertension)

Servanta (artificial surfactant) - indicated for RDS with CXR revealing ground-glass appearance

or L:S < 2:1; adm. 12-24 hrs after symp. appear; P_aO₂ will as atelectasis reverses

Added to regime only after albuterol, Atrovent & IV steroids fail to reverse B.spasm

NOT if PVC's present as can  their occurrence

prototype

Medication vs. Cardiac conditions:

Other:

-  med. dose will  adverse reaction

at bedside (stage 1 & 2; No ABG, CXR, CBC, etc.)

Muscle tone - pt with NM disease or premature infant

Clubbing - consider age of pt. (except CF adolescents)

Deep tendon reflex - differentiates GB vs. MG b/c weakness () with GB diseased

pt vs. normal in MG (MG/Myasthenia Gravis; GB/Guillain-Barre’)

Q_T - for pt with cardiac disease only

PAP - only for cardiac pt or where a Swan-Ganz catheter is already inserted

P_vO₂ only where a Swan-Ganz catheter is already inserted

Allen's test - only before performing an arterial stick at the wrist

Ability to swallow - only in NM disease pt (swallowing difficuly may require intubation)

Swallow ability- for toddler R/O epiglottitis or upper awy obstruction

CVP - only a cardiac pt. or where a central line has been inserted

ABG's - evaluates ventilatory & oxygenation status; however, this painful test

may NOT be necessary if pt is resting comfortably or S_pO₂ = N

ICP - only in head trauma pt's; zero on RA and ONLY before attachment

Tracheal position - ONLY when pneumothorax is suspected

Serum glucose level - only for diabetes or neonatal pt's

Breathe mints - are helpful after pentamidine trx b/c of bad taste

Pulmonary angiogram - procedure to detect pulmonary embolus

Response to painful stimuli - select only when pt is unconscious

Babinski reflex - bottom foot rubbed with dull object, toes inward = N,

toes outward = neurologic defect ONLY i.e. brain damage, - GB; +MG

Gag reflex - tested with NMD determines level of paralysis; also unconscious or

semiconscious - determines depth of depression; caution b/c can cause

vomiting and aspiration; assess level of hazard chocking with MG & GB but

not performed if pt. eating/drinking properly

Electromyography – EMG tests muscle weakness & endurance of NMD i.e. MG

Sx - ONLY PRN; Never q1⁰ or q2⁰, etc.

ABG - ONLY PRN; Never q day

Urine Output - measured (40 ml/hr) to assess cardiac (perfusion) or kidney failure

Bilateral grip test - in NMD tests muscle endurance via hand muscles

CBC (infant) - 30k at birth, 18k at 1 wk, 11k at 2 wk (Wilkens; Assess, p223)

Post Extubation - if offered, choose SVN with Epinephrine X 2 over 2 hour & or

Beclovent MDI X 2 over 2 hour (remember: only if offered)

IPPB with F_IO₂ 1.0 ~ Choose when ABG demonstrates 1) poor ventilation &

2) poor oxygenation and more assessment information is needed

Carotid Artery Message or Valsalva Maneuver ~ common nonelectrical trx for SVT

(Supraventricular Tachycardia) via vagal stimulation.

Lukens Trap- used for collection of sputum during sxing

Expiratory Retard- use to help splint obstructive awys (ie.: wheezes) to remain open

Heimlich Maneuver- performed 1^st 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)

CSE - ALWAYS SELECT

VS - should always be a part of pt evaluation; Also

BP - to assess CV status

Pulse & respiratory rate - assess CP status

Body Temperature - assess presence of infection

LOC - important to evaluate in any pt.

BS - essential to evaluate adventitious air movement through areas of the lungs

MIP - evaluates respiratory muscle strength

cough effort & production - can pt protect airway & presence of Pul infection

V_{t spon.} - evaluates respiratory muscles for effective alveolar ventilation

VC - evaluates effectiveness of cough to protect airways (should be >1,000 ml)

Sputum production - can be diagnostic for infection or other conditions

CBC - to determ O₂ capacity (Hb) and presence of infection (WBC>11K)

CSE - DO NOT SELECT ON THIS EXAM

Hering-Breuer reflex - stretch receptors cannot be evaluated

bowel sounds - provides little relative information about respiratory status

V_D/V_t ratio - time consuming and difficult to assess

O₂ Consumption - hard to tolerate by pt; is also expensive and time consuming

MVV - performed in the PFT lab, it is stressful and offers little information

Moro reflex - performed on infants (startled, they raise their arms up & out)

EEG – can be mistaken for ECG or EKG

PA CXR – must be an AP view ONLY (pt.s are very sick & can not stand)

100 ml V_D is NEVER added to spontaneous breathing pt b/c will PaCO₂

Silverman Score - newborn assessment

Dubowitz Score - estm. gestational age of newborn

PEFR, MIP, VC

S_pO₂ - Except for suspected HbCO poisoning

MIP, VC, RR_spon, V_{t spon.}, RSBI, BS, VS, T, CBC, LOC, CXR, Pulse, when

considering weaning, even if on A/C= 12 but without major acute health issues