CI 2 Viva 1

• what are the benefits of HFNP?


  - Maintain adequate oxygenation PLUS humidification

  - provides small amount of PEEP (if mouth closed)

  - patient still able to talk, walk, eat
• what are the contraindications to HFNP?


  - significant facial trauma

  - patients requiring continuous nebulisers

  - any condition where positive pressure would be a problem
• provide an example of a condition in which positive pressure would be harmful

  undrained pneumothorax
• name the two conditions which commonly require induced sputum?

  tuberculosis, PCP
• describe the process of induced sputum

  - inhalation of hypertonic (6%) saline over several minutes

  - movement of fluid draws diseased cells across the alveolar membrane to allow detection on sputum sample

  - usually takes 20-30 minutes
• when should humidification be used?


  if your patient requires continuous oxygen therapy (especially at high flow rates) for >24hrs +/- your patient already has problems with sticky sputum
• what might be needed if your patient is unable to maintain their oxygen levels with increased oxygen flow

  they might need positive pressure to augment their oxygenation
• name two methods by which positive pressure can be administered to patients unable to maintain their oxygen stats

  invasive ventilation or non-invasive ventilation
• name the two interfaces use for invasive ventilation

  endotracheal tube, tracheostomy
• how should ETT's be placed?


  inserted through the mouth & larynx, should terminate 3-5cm above the carina
• ETT's are usually limited to...

  7 days
• What is a tracheostomy?


  direct opening into a persons airway, bypassing the upper airway
• what are the indications for a temporary tracheostomy?


  MV with ETT (intubation) >10-14 days

  Comfort

  Long term unconsciousness or coma

  Glossal muscle paralysis / inability to swallow

  Loss of laryngeal reflexes

  Foreign body

  Severe neck or mouth injuries

  Inhalation injuries (steam, smoke, corrosive material)

  decreases risk of aspiration

  decreases airway compression/ obstruction (protection)

  Aids secretion removal
• list the types of tracheostomys


  mini-tracheostomy, surgical, percutaneous, cricothyroidotomy
• when are mini-tracheostomy's and cricothyroidotomy's used?


  mini: secretion management

  circothyroidotomy: emergency
• what is the role of the inflated cuff in a tracheostomy?


  - isolates the upper airway from the lower
• what happens if a cuff in a tracheostomy is deflated?


  provides theopportunity for air to move through the upper airway
• what are the risks associated with an underinflated tracheostomy cuff?


  aspiration of secretions

  underventilation (in MV)
• what are the risks associated with an over-inflated tracheostomy cuff?


  tracheomalacia

  tracheo-oesophesgeal fistula

  inflammation of the trachea wall

  formation of granulation tissue

  tracheoinnominate fistula

  tracheal stenosis
• what happens to airways and secretions with a tracheostomy?

  With a trache, the upper airway is bypassed and the humidification is compromised

  The lower airway becomes drier as a result.

  The cilia of the lower airway are then less effective at clearing secretions.
• what are the signs of poor humidification in a patient with a tracheostomy


  1. secretions sticking to the inside of the tube

  2. thicker sputum moves up the suction catheter or is seen on the outside of the catheter

  3. an absence of sputum

  4. bleeding from the tracheal wall

  5. atelectasis due to sputum plugging
• list 7 methods of preventing cardiovascular disease

  1. decreasing weight

  2. healthy diet

  3. stop smoking

  4. decrease BP

  5. decrease stress, anxiety and depression

  6. increase PA

  7. medication adherence
• List 8 modifiable risk factors for CVD.

  high cholesterol, high BP, diabetes, overweight, smoker, physically inactive, depression/ psychological issues, poor nutrition
• list the 12 absolute contraindications for exercise

  1. progressive worsening of exercise tolerance or dyspnoea at rest or on exertion over previous 3-5 days

  2. significant ischemia at low exercise intensities

  3. uncontrolled diabetes

  4. acute systemic illness or fever

  5. recent embolism (<4 weeks)

  6. thrombophlebitis

  7. active pericarditis or myocarditis

  8. severe aortic stenosis

  9. regurgitate valvular heart disease requiring surgery

  10. myocardial infarction (MI) within previous 3 weeks

  11. new onset atrial fibrillation

  12. Resting HR >120bpm
• name the 8 absolute contraindications to exercise

  1. new or uncontrolled arrhythmias

  2. resting or uncontrolled tachycardia

  3. uncontrolled hypertension (resting SBP >180 mmHg or resting DBP >100 mmHg)

  4. symptomatic hypotension

  5. unstable angina

  6. unstable or acute heart failure

  7. unstable diabetes

  8. febrile illness
• name 5 benefits of exercise for COPD patients

  1. improved aerobic capacity

  2. improved symptoms of breathlessness

  3. improved cardiac function

  4. improved anthropometric variables

  5. improved functional status and quality of life
• what are the goals of pulmonary rehabilitation


  increased exercise tolerance, improve adherence to recommended treatments, improve mood and motivation, reduce frequency and severity of symptoms and increased survival, reduced dependency and build self-management capacity, increase participation in everyday activities and improve QOL, reduce health care burden for patients, families and communities
• what are the criteria for domiciliary oxygen?


  stable chronic lung disease, PaO2 <55 at rest on room air, condition must be stable and all reversible factors (e.g. anemia) remediated, must have gone at least 1 month without smoking
• what are the three groups of asthma medications?

  relievers, preventers, symptom controllers
• T/F There is a drug which has been found to modify the lung function that declines in COPD

  F

  There is not a drug which has been found to modify the lung function that declines in COPD
• Contraindications for MHI


  - undrained pneumothorax or the presence of an ICC with a continuous leak

  - bronchopulmonary fistula

  - recent oesophageal or lung surgery

  - acute respiratory distress syndrome (ARDS)
• precautions for MHI


  - unstable CVS (unstable arrhythmias, mean arterial pressure <65mmHg, high inotropic support)

  - bronchospasm

  - PEEP >15cm H2O

  - patient is PEEP dependent or high risk of derecruitment if disconnected from the ventilator

  - pressure support + PEEP >30cm H2O

  - FiO2 >60%

  - raised or unstable ICP

  - florid acute pulmonary oedema

  - restrictive or obstructive lung disease

  - significant pulmonary hypertension or right ventricular dysfunction
• name the three benefits of MHI


  - mobilising sputum

  - reversing atelectasis

  - improving oxygenation and pulmonary compliance
• is MHI or VHI more effective


  neither! both equally effective

  however, VHI used when patients unable to be transiently removed from ventilation for MHI
• what are the risks of prolonged ventilation?


  ventilator associated pneumonia

  respiratory muscle weakness
• what are the risks of failed extubation and reintubation?

  increased risk of mortality, increased duration of ventilation, increased length of ICU admission
• name the 4 factors to be considered when assessing capacity for extubation

  1. overall mental capacity

  2. coached ventilatory capacity

  3. ability to clear secretions independently

  4. secretion load
• when should IMT be used in ventilated patients?

  - patients alert and able to participate

  - not excessive PEEP (>15cm H2O)

  - stable RR (<25)

  - Medically stable

  - if ventilator dependent >7 days and or difficulty weaning

  - high intensity (>50%) interval threshold training safe

  - consider electronic devices if MIP <20cm H2O
• when should IMT be used following weaning from ventilation?


  - if ventilated > 7 days

  - high intensity interval training will increase strength and QOL within 2 weeks

  - target moderate MIP and QOL for optimum gains

  - consider progressing to electronic devices if hit 41cm H2O ceiling on threshold device
• list 6 benefits of early mobilisation for ICU patients?


  - improved outcome at 1 year post ICU

  - reduced delirium

  - improved functional outcomes

  - decreased MV days

  - decreased hospital days

  - decreased cost of care