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NR.646 Advanced Pediatric Acute Care
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(NAVA) Neurally Adjusted Ventilatory Assist - correct correct answer>>>>>>*Uses the signals of the diaphragm to run the ventilator *Each breath is assisted by variable pressure support based on the strength of signals coming from the diaphragm.
- Most comfortable mode of ventilation Patient MUST be breathing with their diaphragm %I-Time (33%-50%) - correct correct answer>>>>>>Because the machine is going so quickly, an actual inspiratory time cannot be set like on a regular ventilator. *Instead, it is set as a % of the cycle that the machine is on the "Inspiratory" or inflating portion of the breath *an increase may increase Vt however, it is rarely changed from 33% 1 - month-old male is intubated with ventilator settings to include SIMV with pressure support in the ICU. The ventilator rate is 20, PIP pressure is 20 and PEEP of 8. You are notified of the following blood gas results: pH 7.30/PaCO2 64/PaO2 91/HCO3 24. Which of the following is the most appropriate ventilator adjustment? - correct correct answer>>>>>>Increase ventilator rate 2 - 5 years pneumonia - correct correct answer>>>>>>virus still common Increase in Streptococcus pneumoniae and Haemophilus influenzae type B Tx: High dose amoxicillin or beta lactam 4 - year-old child was diagnosed with Streptococcal pneumoniae pneumonia 4 days ago and was started on high dose amoxicillin, Today, he develops new increased respiratory distress and fever. What do you anticipate is the rationale? - correct correct answer>>>>>>Parapneumonic effusion/empyema
5 - 13 years pneuomia - correct correct answer>>>>>>Mycoplasma pneumonia: streptococcus pneumoniae Tx: Macrolide (Azithromycin) pneumococcal: PCN, clindamycin A 10-year-old male is intubated in the ICU. You are called to evaluate and intervene on the following blood gas: pH 7.41/PaCO2 38/PaO2 61/HCO3 24 - correct correct answer>>>>>>Increase positive end expiratory pressure (PEEP) A 13 month old, 11kg child, presents with strider and low grade fever with history of 5 days illness with cold symptoms and cough. The child was treated with humidified air and acetaminophen, but his work of breathing increased. Oxygen saturation on room air is 94%. What is the recommended first step in treatment? - correct correct answer>>>>>>Dexamethasone 6.6mg given oral/IM A 2 year old has had cold symptoms for the past week and now has significant stridor which increases with mild activities. He is evaluated in the ED and found to be hypoxic. What would be an expected finding on the neck radiograph? - correct correct answer>>>>>>Steeple Sign A 2-year-old boy is admitted to the hospital with dehydration and hypotension. Electrolytes show Na+ 165 mEq/L, K+ 4.0 mEq/L, CO2 32 mEq/L, Cl- 112 mEq/L. No arterial blood gas is obtained. Does this patient have metabolic acidosis? - correct correct answer>>>>>>Yes: his anion gap is 165 - (32 + 112) = 21 mEq/L. Despite the fact that CO2 is elevated (reflecting a metabolic alkalosisfrom dehydration), there is also a slight metabolic acidosis; the acidosis is from lactic acidosis, a result of the hypotension and poor organ perfusion. A 2-year-old boy is admitted to the hospital with dehydration and hypotension. Electrolytes show Na+ 165 mEq/L, K+ 4.0 mEq/L, CO232 mEq/L, Cl- 112 mEq/L. No arterial blood gas is obtained. When presented with a set of electrolytes and the possibility of an acid-base disorder, you should make the following calculations. - correct correct answer>>>>>>1. Anion gap (AG) = Na+ - (Cl- + CO2) = 165 - (112 + 32) = 21 mEq/L 2. delta AG = AG - normal anion gap = 21 - 12 = 9 mEq/L 3. delta CO2 = normal CO2 - measured CO2= 27 - 32 = - 5 mEq/L 4. Bicarbonate gap = delta AG - delta CO2= 9 - (-5) = 14 mEq/L A 2-year-old is post-op day #0 from placement of a tracheostomy. The child experiences an acute desaturation episode and chest is not moving despite ventilation with hand bagging. What is the most appropriate intervention? - correct correct answer>>>>>>Remove trach, place gauze over trach site, and bag over mouth/nose acute respiratory distress syndrome (ARDS) - correct correct answer>>>>>>a form of the sudden onset of severe lung dysfunction affecting both lungs, making breathing extremely difficult
bilevel positive airway pressure (BiPAP) - correct correct answer>>>>>>*Provides two levels of pressure: Inspiratory positive Airway Pressure (IPAP)-triggered when it senses inspiratory effort *Expiratory Positive Airway Pressure (EPAP)-delivers EPAP until it senses the next inspiratory effort *More support then CPAP Need a calm/cooperative patient Biphasic Cuirass Ventilation (BCV) - correct correct answer>>>>>>Non-invasive shell that actively controls both phases of the respiratory cycle:Pressure acts uniformly over the thorax = uniform lung expansion *Negative pressure generated for inspiration Positive pressure generated for expiration Cation - correct correct answer>>>>>>A positively charged ion Combined: Pressure regulated volume control - correct correct answer>>>>>>Assist control mode delivers a set tidal volume with a variable pressure breath to breath based on compliance changes Compliant lungs require lower pressure - correct correct answer>>>>>>Risk of volutrauma from stretch in spite of low pressures Consider both lung compliance and chest wall compliance (resistance to expansion) - correct correct answer>>>>>>May need to use sedation/neuromuscular blockade to overcome chest wall compliance issues Consider chest wall compliance with significant body edema Contraindications to NIV Absolute - correct correct answer>>>>>>Absolute: Apnea, Shock, Cardiopulmonary arrest, Decreased LOC with GCS<8, unable to protect airway, recent facial surgery/facial fractures Contraindications to NIV Relative - correct correct answer>>>>>>Relative: Vomiting, Confusion/Agitation, Chest Trauma, Hemodynamic instability, Facial/airway burns, Bullae, Recent GI surgery, Excessive secretions, bowel obstructions, nasal obstructions/atresia, epistaxis CPAP - correct correct answer>>>>>>Assistive mode of ventilation-requires respiratory drive *Increases inspiratory pressure and maintains PEEP (positive end expiratory pressure)
- Increase FRC by overcoming elastic forces
- Decrease/Prevent atelectasis
- Improve V/Q mismatch
- Can overcome upper airway obstruction *Smaller airways and alveoli are open with exhaling against resistence *Works well for small infants with low FRC
- May be challenging to find appropriate fir for mask *Used frequently to treat apnea-mainly Obstructive Sleep Apnea (OSA) Interfaces-nasal prongs, nasal mask, full face mask CPAP + Pressure Support - correct correct answer>>>>>>CPAP allows the patient to breath spontaneously at an elevated positive pressure baseline. *PS is an option for spontaneous breaths only. *PS purpose is to overcome the resistance of the tubing *PS: when the patient triggers, inspiration is assisted at a preset pressure Croup (laryngotracheobronchitis) most common etiology - correct correct answer>>>>>>parainfluenza virus type 1 and 2 Croup diagnosis film - correct correct answer>>>>>>Lateral Neck film (Steeple sign) Croup incidence - correct correct answer>>>>>>3months-5years risk of recurrent episodes Northern hemisphere Between October-March Croup pathophysiology - correct correct answer>>>>>>decreased airway diameter and increased resistance to airflow airway edema epithelial necrosis Croup S/S - correct correct answer>>>>>>1. barking cough
- stridor
Documentation describes the following aspects of care - correct correct answer>>>>>>What was heard (history) What was seen (exam) What was thought (medical decision making) Dx considerations for - Bicarbonate Gap (>-6mEq/L) - correct correct answer>>>>>>The serum CO2 is reduced more than predicted by the change in the anion gap, and suggests: A) hyperchloremic metabolic acidosis &/or B) bicarbonate excretion as compensation for respiratory alkalosis Dx considerations for +Bicarbonate Gap (>6mEq/L) - correct correct answer>>>>>>The serum CO2 is reduced less than predicted by the change in the anion gap and suggests: A) metabolic alkalosis &/or B) bicarbonate retention as compensation for respiratory acidosis Edi Min: - correct correct answer>>>>>>Spontaneous tonic activity of diaphragm maintains PEEP Edi Peak - correct correct answer>>>>>>diaphragm effort, determines size and duration of breath Edi Trigger: - correct correct answer>>>>>>amount of electrical activity needed to trigger the ventilator to provide a breath Edi: - correct correct answer>>>>>>electrical activity of the diaphragm Elastic recoil of chest wall - correct correct answer>>>>>>outward pull Elastic recoil of lung - correct correct answer>>>>>>inward pull Elevated AG with a significant variation of bicarbonate gap form zero, either + or - suggests... - correct correct answer>>>>>>mixed acid-base disorder; anion gap acidosis plus another disorder, such as metabolic alkalosis (+bicarbonate gap) or hyperchloremic metabolic acidosis (- bicarbonate gap) Empyema - correct correct answer>>>>>>Spread of infection (bacterial) into the pleural fluid Fluid is purulent when drained Antibiotics mainstay of therapy. May require thoracotomy/chest tube +/- fibrinolytic administration, VATS Epiglottitis - correct correct answer>>>>>>severe, life-threatening infection of the epiglottis
Acute-happens quickly Has decreased steadily since Hib vaccine Most common path is Staph aureus and Strep pneumoniae Most common in kids 1-5 years "Hot Potato Voice" Epiglottitis treatment - correct correct answer>>>>>>assume position of comfort noxious stimuli must be avoided be ready to intubate with humidified oxygen antibiotics- 3rd gen cephalosporin 7-10 days of therapy consider systemic steroids IVF to prevent dehydration Evaluate Settings - correct correct answer>>>>>>Patient Exam:
- Chest rise-equal, not good, great, or too little
- Air entry
- Comfort
- Synchrony of patient/vent breaths
- Adequte vent-based on end tidal CO2 and blood gas *Evaluate pressure and volume flow loops Example of Bicarbonate gap with an anion gap acidosis with only acid-base abnormality - correct correct answer>>>>>>delta AG=patient's AG-12mEq/L delta CO2=27 mEq/L - patient's CO AG goes up by 10mEq/L to 22 mEq/L then serum CO2 should go down by 10 mEq/L to 17 mEq/L; in this case delta AG - delta CO2=10-10=0 bicarbonate gap
High Flow Nasal Cannula (HFNC) - correct correct answer>>>>>>*Provides heated flow with high humidity and can provide higher FiO
- Devices can deliver up to 60L of flow
- Usually start at 1-2L/min/kg for infants/children
- Oxygen can be blended to provide higher flow, but less oxygen *Provides low level positive pressure:may be similar to CPAP Typically well tolerated High Frequency ventilation - correct correct answer>>>>>>High frequency oscillatory ventilation (HFOV) *High Frequency Jet Ventilation (HFJV) *Deliver small tidal volumes at a very high rate and set a mean airway pressure - Tidal volume about 1 mL/kg - Rates 180-1200 breaths /min High Frequency Ventilation used to prevent _______ and ________ with high vent settings - correct correct answer>>>>>>volutrauma and barotrauma *Air leak syndromes, ARDS Hypercarbia - correct correct answer>>>>>>increased carbon dioxide in the blood Hypoxemia - correct correct answer>>>>>>decreased oxygen in the blood Hypoxemia/Hyperventilation - correct correct answer>>>>>>Anxiety, fear Pain Fever Stimulants CNS irritation (eg central hyperventilation) Excessive ventilatory support i-Time - correct correct answer>>>>>>The time frame for the delivery of the tidal volume. neonate/infant 0.4-0.6 sec all else 0.6-0.8 sec If you increase your PEEP you increase your? - correct correct answer>>>>>>Oxygenation
Impaired Oxygenation - correct correct answer>>>>>>*Low oxygen content-anemia, higher altitude *Shunt *Ventilation/Perfusion (V/Q) mismatch *Poor delivery of oxygen-obstruction of blood flow or fluid accumulation Oxygen diffusion issue-failure to diffuse across alveolar membrane Impaired ventilation - correct correct answer>>>>>>Poor diffusion of CO *Increased dead space *Hypopnea-too few or too small of breaths Increased airway resistance in young children, small airways are easily compromised by - correct correct answer>>>>>>inflammation, edema and mucous plugging Increased Hgb and Hct - correct correct answer>>>>>>dehydration Interprofessional patient care - correct correct answer>>>>>>integrated approach in which members of a clinical team actively coordinate care and services across disciples IT (Inspiratory Time) - correct correct answer>>>>>>Amount of time it takes to inhale or deliver the breath Laryngotracheobronchitis (Croup) - correct correct answer>>>>>>Concerned mostly at night because respiratory effort increases when you lay down. Late onset neonatal pneumonia - correct correct answer>>>>>>Staphylococcus and streptococcus Tx: Ampicillin, plus aminoglycoside or 3rd gen cephalosporin EES or azithromycin for chlamydia Lovenox is classified as a/an: - correct correct answer>>>>>>Anticoagulant- low molecular weight heparin Low lung compliance - correct correct answer>>>>>>stiff lung and needing extra work to obtain normal lung volume
Non-invasive ventilation - correct correct answer>>>>>>Continuous Positive Airway Pressure (CPAP) Bilevel Positive Airway Pressure (BiPAP) Non-invasive ventilation (NIV) goal - correct correct answer>>>>>>provide similar benefits of mechanical ventilation while reducing risk of lung injury and infection Normal Bicarbonate levels HCO3 - correct correct answer>>>>>>22-26 mEq/L Normal CO2 levels - correct correct answer>>>>>>35-45 mmHg Normal Mean Anion gap - correct correct answer>>>>>>12.4 mEq/L Normal pH value - correct correct answer>>>>>>7.35-7. Obstructive sleep apnea symptoms sever cases - correct correct answer>>>>>>Pulmonary hypertension, cor pulmonale Older infants/toddlers pneumonia (30 days-2 years) - correct correct answer>>>>>>Viral etiology Tx: >3mo High dose amoxicillin or beta lactam Oscillator Power (0-10 or 0 to 100 cop delta P) - correct correct answer>>>>>>The degree of oscillation within the circuit around the MAP. (sort of like the PIP on a regular ventilator) *This is the setting that determines how vigorously the patients chest is vibration *an increase improves ventilation Oxygenation issues generally adjust: Mean airway pressure & FiO2 - correct correct answer>>>>>>Ventilation issues, generally adjust: Power or Delta P Frequency (go opposite from a regular ventilator - up will increase CO2, down will reduce CO2) PaO2 normal range - correct correct answer>>>>>>80-100 mm Hg Parapneumonic effusion - correct correct answer>>>>>>Common in bacterial pneumonia (generally small); will resolve with appropriate antibiotic therapy. May require drainage if moderate/large in size. Commonly transudative. Pleura is inflamed; leakage of proteins. Fluid is sterile with low leukocyte count.
PCO2 65 (Hypercarbia) - correct correct answer>>>>>>Respiratory acidosis typically occurs due to failure of ventilation and accumulation of carbon dioxide. The primary disturbance is an elevated arterial partial pressure of carbon dioxide (pCO2) and a decreased ratio of arterial bicarbonate to arterial pCO2, which results in a decrease in the pH of the blood. PE Diagnosis - correct correct answer>>>>>>Elevated D-Dimers VQ Scan Helical spiral CT scan (Dependent on radiologist experience) PEEP (Positive End Expiratory Pressure) or CPAP (Continuous Positive Airway Pressure - correct correct answer>>>>>>The amount of pressure maintained in the lungs- either at the end of the the expiration (PEEP) or at all times (CPAP) PEEP disease severity "normal" lungs status asthmaticus or airway obstruction hypoxic lung disease - correct correct answer>>>>>> 0 - 5 8 - 10 Peritonsillar abscess - correct correct answer>>>>>>Hot potato voice Swollen tonsils with uvula deviation Broad Spectrum antibiotic Lanced in ED Older child so no risk of airway obstruction Pertussis - correct correct answer>>>>>>Whooping Cough Concern in infants less than 2 months of age possibly present with apnea. Highest mortality rate <6m CBC typical lab finding Leukocytosis Lymphocyte predominance; 50-80,000/cm Pertussis treatment - correct correct answer>>>>>>Treat with Macrolide Erythromycin, clarithromycin and azithromycin pH of 7.23 - correct correct answer>>>>>>Acidotic
Pressure control Disadvantages - correct correct answer>>>>>>Can't guarantee minute ventilation Compliance variations may lead to too much or too little tidal volume Pressure regulated - correct correct answer>>>>>>delivers a pressure-limited breath during a predetermined inspiratory time PS (Pressure Support) - correct correct answer>>>>>>Only used on spontaneous breaths, adds extra pressure to assist patient overcome the resistance of the endotracheal tube-makes it easier to breath through the tube Pulmonary Embolism more common in - correct correct answer>>>>>>Obese teens taking birth control pills Pulmonary function tests - correct correct answer>>>>>>a group of tests that measure volume and flow of air by utilizing a spirometer (ASTHMA) Rate - correct correct answer>>>>>>Depends on age; typically start at 12- 30 Residual volume (RV) - correct correct answer>>>>>>air left after max exhaled (25% TLC) *TLC=VC + RV Resource-Based Relative Value Scale - correct correct answer>>>>>>RBRVS-reimbursement based pay scale Respiratory Acidosis - correct correct answer>>>>>>Hypoventilation CNS depression (anesthesia, narcotics, sedatives, drug overdose) Respiratory neuromuscular disorders Trauma spine, brain, chest wall Restrictive lung disease Chronic obstructive pulmonary disease Acute airway obstruction (late phase) Respiratory Failure - correct correct answer>>>>>>Inability to oxygenate and ventilate Retropharyngeal abscess - correct correct answer>>>>>>life-threatening infection in the lateral pharyngeal space that has the potential to occlude the airway; most commonly occurs in children 1-5 years of age Polymicrobial (Strep pyogenes, Staph aureus, Haemophilus)
Retropharyngeal abscess Diagnostic eval - correct correct answer>>>>>>CBC with diff Leukocytosis Blood culture Lateral neck film: Widening of retropharyngeal soft tissues; widening of prevertebral space. may differentiate RPA from epiglottitis CT scan of neck with IV Contrast: Identifies extent of infection and differentiate abscess from cellulitis Chest X-ray: Eval for mediastinal expansion RR Respiratory rate - correct correct answer>>>>>>The number of times the machine is delivering the breaths in one minute RVU - correct correct answer>>>>>>Relative value unit: A method to calculate fees for services. A unit is translated into a dollar value using a conversion factor or dollar multiplier. The assigned value is generally based on three factors: physician work component, overhead practice expense, and malpractice insurance. Short cut for bicarbonate gap equation - correct correct answer>>>>>>BICARBONATE GAP = delta AG - delta CO2= [AG - 12] - [27 - CO2] = [(Na+ - Cl- - CO2) - 12] - [27 - CO2] = Na+ - Cl- - 39 SIMV - correct correct answer>>>>>>*Ventilator will deliver a preset number of breaths that it attempts to "Synchronize" with the patients effort *All breaths above set rate will be pressure supported breaths that have a preset pressure to support patient initiated breaths above the set rate *Can be used as a weaning mode-decreasing rate as increasing patient effort SIMV (Pressure Control) + Pressure Support - correct correct answer>>>>>>A specific PIP and RR are set. This is the maximum number of ventilator breaths the patient will receive in one minute. *The patient can breath whenever they want, but if it is "time-for" a mechanical breath, the ventilator will deliver the preset PIP instead of a pressure support or CPAP breath
- Much more comfortable than control modes
Tx: Usually just time!! Severe may need surgery (tracheostomy & CPAP in severe cases) Vent Settings FiO2 - correct correct answer>>>>>>how much oxygen does the patient need Vent Settings iTime - correct correct answer>>>>>>the time spent in inspiratory phase Vent Settings Peak inspiratory pressure - correct correct answer>>>>>>set limits, but depends on lung compliance Vent Settings PEEP - correct correct answer>>>>>>Physiologic is about 3-4 cm H2O: often start with 5 Vent Settings Rate - correct correct answer>>>>>>will vary based on age, level of sedation, and disease process Vent Settings Tidal volume - correct correct answer>>>>>>Based on size of patient Typically 6-8 mL/kg May adjust based on ideal bodyweight Adult size patients max out around 500-650mL Ventilation drives removal of - correct correct answer>>>>>>CO Ventilator associated lung injury associated with ARDS - correct correct answer>>>>>>Permissive hypercapnia, low tidal volume, avoid PIP > Vital Capacity (VC) - correct correct answer>>>>>>max amount of air exhaled after max inhaled Volume Control advantages - correct correct answer>>>>>>You control minute ventilation Better at preventing volutrauma based on set TV Volume Control Disadvantages - correct correct answer>>>>>>Constant flow pattern may no meet patients needs. May lead to more asynchrony with patient Can result in a higher PIP than a similar TV for PC mode Volume Regulated - correct correct answer>>>>>>Delivers a set tidal volume during a preset inspiratory time VT or TV (Tidal Volume) - correct correct answer>>>>>>volume of air inhaled or exhaled in one breath cycle
What are the acid-base disorders in a 8-year-old boy who presents to the ED with several days of vomiting, nausea and abdominal pain. His blood pressure is low and he has tenting of the skin. He has the following electrolytes: Na+ 144 mEq/L Cl - 95 mEq/L K+ 4.2 mEq/L CO2 14 mEq/L - correct correct answer>>>>>>1) Calculate the anion gap: AG = Na+ - (Cl- + CO2) = 144 - (95 + 14) = 35 2) Calculate delta AG. (Be sure to use normal AG in your lab.) 35 - 12 = 23 3) Calculate delta CO227 - 14 = 13 4) Calculate the bicarbonate gap: delta AG - delta CO223 - 13 = 10 mEq/L SHORTCUT: Na+ - Cl- - 39 144 - 95 - 39 = 10 mEq/L What evidence based therapy for an infant with low grade fever, rhinorrhea, cough, tachypnea, wheezing, who is admitted to the pediatric floor and found positive for respiratory syncytial virus - correct correct answer>>>>>>Oxygen, suctioning, supportive care What is expected on the chest radiograph of a child with status asthmaticus? - correct correct answer>>>>>>Flattened diaphragms from Hyperinflation What is the acid-base disorder(s) evident in the following values, from a 17-year-old girl with acute renal failure? Na+ 140 mEq/L K+ 4 mEq/L Cl - 115 mEq/L CO2 5 mEq/L pH 7.12 PaCO2 13 mm Hg HCO3- 4 mEq/L - correct correct answer>>>>>>Clearly, the blood gases indicate a state of metabolic acidosis. But what type or types? 1) Calculate the anion gap: AG = Na+ - (Cl- + CO2) = 140 - (115 + 5) = 20 2) Calculate delta AG: 20 - 12 = 8 3) Calculate delta CO2: 27 - 5 = 22 4) Calculate the bicarbonate gap: delta AG - delta CO28 - 22 = - 14 SHORTCUT: Na+ - Cl- - 39 140 - 115 - 39 = - 14 mEq/L Her bicarbonate gap is significantly reduced at - 14 mEq/L. Thus her measured CO2 is 14 mEq/Llower than we would expect from the excess anion gap alone. Stated another way, the acid or acids causing her anion gap should have lowered venous CO2 only to about 19 mEq/L; that her venous CO2 is actually 5 mEq/L indicates an additional reason for the acidosis, in this case hyperchloremic metabolic acidosis. Such a situation is fairly common in patients with renal failure, who have uremia (causing elevated AG metabolic) and interstitial nephritis (causing hyperchloremic metabolic acidosis, which doesn't elevate the AG). What management strategies is recommended when managing an infant with pertussis? - correct correct answer>>>>>>Chemoprophylaxis is recommended for all household contacts What medication can cause hypertrophic pyloric stenosis in infants <1month of age - correct correct answer>>>>>>Azithromycin
