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86 Cards in this Set
- Front
- Back
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Goals of Mechanical Ventilation
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adequate gas exchange
prevent/reverse atelectasis maintain optimal FRC Ensure optimum pulm. C Decreased WOB Eliminate Resp. Fatique |
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What is indicated If an infant weighs less than 1000 g
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immediate intubation & ventilation
(to decrease stress & conserve surfactant) |
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Initial PIP
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15-20 cmH2O
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What is the primary adjustment when in FVS using PCV?
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PIP
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What are the weaning parameters for CPAP
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decrease FiO2 in 0.05 increments until 0.40-0.60 then
decrease CPAP in increments of 2 cmH2O as tolerated (ABG); when at 2-3 cmH2O, CPAP can be removed. Monitor continuously w/pulse ox &/or transcutaneous monitor |
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Indications for CPAP
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Decreased FRC
Airway Collapse Weaning from MV Abnormal physical exam Abnormal ABG's |
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Upper pressure limit for CPAP on children/infants
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12 cmH2O and less
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The application of CPAP has what clinical benefits
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increases FRC which leads to:
increased C decreased WOB increased PaO2 while delivered FiO2 is decreased |
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What are the desired outcomes of CPAP
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increased FRC & C
decreased Raw & RF |
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Conditions that decrease the FRC
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pneumonia
atelectasis pulmonary edema meconium aspiration RDS |
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Conditions in which the airway is collapsed
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tracheobronchial malacia
apnea |
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Abnormal physical exams that indicate the need for CPAP
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RF increased 30-40%
retractions grunting nasal flaring cyanosis |
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What PaO2 at an FiO2 of 0.60 indicates a need for the application of CPAP
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PaO2 < 50 mmHg at FiO2 of .60 (with adequate ventilation)
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What are the contraindications of CPAP
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Upper airway abnormalities (choanal atresia or cleft palate)
untreated air leaks like pneumothorax severely apneic patient hypercapnic respiratory failure |
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What are the indications of the proper amount of PIP?
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appropriate bilateral chest expansion
bilateral aeration on auscultation adequate PaCO2 |
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How is RF determined when given the Ti and Te?
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Add Ti and Te then divide into 60
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Initial RF
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30 to 40 breaths/min
can be increased up to 150 when severe ALI is present |
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Initial Flow Rate
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6-8 L/min
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Initial Tidal volumes set
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very low birth wt. 4-6 ml/kg
term 8-10 ml/kg |
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What determines that tidal volume delivered when using PCV
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the change in airway pressure between the PIP and PEEP as well as the C & Raw of the pt
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Initial PEEP setting
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3-5 cmH2O
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Initial FiO2
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keep SpO2 90-92% or to keep pt. pink
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Initial set Inspiratory time
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low birth wt. .25-.50 sec
term 0.5-0.6 |
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Initial I:E ratio
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1:1.5 to 1:2
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Initial Tidal Volumes
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very low birth wt. 4-6 ml/kg
low birth wt. 6-8 ml/kg term 8-10 ml/kg |
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"Conventional" Neonatal Ventilation
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Time triggered
pressure limited time cycled |
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what are the two determinates of the I:E ratio?
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Ti and RF
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what set variable determines how much time the inspired gas is in contact with the alveoli
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Ti
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How is airtrapping prevented when the ventilator rate is increased
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reduce Ti
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What are adverse reactions to high levels of PEEP
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increased dead space
reduced CO |
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what are some of the uses of PEEP
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stint the airway open
increase FRC Increase oxygenation allow lower levels of PIP |
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Define MAP
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MAP is the average P exerted on the airways & Lungs from the start of I until the begining of the next I (or 1 resp. cycle)
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What factors affect MAP?
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PIP
PEEP Ti RF |
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What is the most powerful influence on oxygenation?
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MAP
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What are some adverse affects of MAP
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decreased CO
Pulmonary Hypoperfusion Increasesd risk barotrauma |
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Equation to calculate MAP
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MAP=
PIP x (Ti/TCT) + PEEP x (Te/TCT) |
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How is tidal volume calculated
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Vt = Ti x Flow rate
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Any adjustment made to the flowrate will alter which parameters?
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PIP
PEEP CPAP |
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define opening pressure
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the amt. of P required to open & expand the alveoli
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Define driving pressure and how is it calculated
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amt. of P rise during ventilation
PIP - PEEP |
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What relationship between the driving P and the opening Pis required in order to ventiate
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Driving P greater than or equal to the opening P in order to ventilate
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What effect does PEEP have on the opening & driving pressures
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PEEP improves C therefore opening P is reduced and less Driving P is required to ventilate
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Define Time Constant (KT)
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the amount of time required for the alveolar and proximal P to equilibriate
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What determines the Expiratory Time Constant
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Lung compliance and airway resistance
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1 KT is equal to
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the time to exhale 63% of the Tidal Volume
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How are KT calculated
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KT = C x Raw
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What mode of ventilation does the "conventional" mode of ventilation mimic?
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PC-IMV but functions more like PC-CMV with no trigger capacity
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What are the primary treatment modalities for neonatal respiratory failure
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CPAP and
time cycled, pressure limited IMV |
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Goals of MV
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1. acheive & maintain adequate gas exchange
2. minimize risk of lung injury 3. reduce WOB 4. optimize pt. comfort |
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What modes are available for noninvasive neonatal ventilation
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CPAP
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What are the benefits of administration of CPAP
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recruitment of alveoli
increased lung volume regulates breathing pattern reduced thoracic distortion stabilizes chest wall splinting of airway & diaphragm decreases obstructive apnea enhances surfactant release |
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Complications associated with administration of CPAP
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abdominal distention & feeding difficulties
nasal irritation &/or injury thoracic air leaks; reduced venous return & CO |
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What mode of ventilation is used when lung protective strategy is required
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PSV; overcomes Raw; onset, duration & frequency are patient controlled; level of support set; flow variable & proportional to pt. effort.
Used primarily for weaning |
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what are the various modes of "patient triggered" ventilation
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SIMV, AC and PS
mechanical breath is given in response to measured resp. effort by pt. |
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With pressure limited MV, what variables are indepent & which are dependent
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Independent: consistent PIP
Dependent: Tidal Volume varies with C |
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With Pressure targeted MV, what variables are independent & which are dependent
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Ti is constant & PIP set
flow & tidal Volume is variable |
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What is the frequency range for HFJV
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240-660 breaths/min
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what mode of ventilation is used to treat thoracic air leaks
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HFJV and pulmonary interstitial emphysema
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With HFJV how is ventilation determined
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ventilation determined by amplitude & frequency
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How does HFOV differ from HFJV
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in HFOV exhalation is active (machine performs both I/E)whereas in HFJV exhalation is passive (pt. must exhale)
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HFOV parameters that indicate/adjust oxygenation and ventilation
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MAP = oxygenation
Amplitude = ventilation |
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What clinical factors must be present for ECMO to be indicated
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>80% chance of death
>2 kg infant weight and 34 weeks or older gestational age |
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Clinical uses of Monitoring graphics
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assessment of synchrony
effects of tx interventions customization of MV settings according to pt & diseas |
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Other Uses of Monitoring graphics
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gives early indication of airtrapping/hyperinflation
can use to determine optimal PEEP and estimate WOB gives immediate feedback on effects/changes in vent. parameters |
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What are 2 rescue therapies for infants who fail to respond to conventional tx
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HFV and ECMO
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Benefits of CPAP/PEEP
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increases FRC
Improves oxygenation prevent/reverse atelectasis |
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HFOV indications include:
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air leaks (pneumothorax, PIE)
reduce barotrauma conventional MV is failing |
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When changing to HFOV from conventional MV what preparations must be made?
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Art line in place
Continuous monitoring of: BP, EKG, RR & SPO2 CXR w/in 30-60 min post initiat chest expansion w/HFOV pf 8.5 to 9 ribs |
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How is proper inflation determined when initiating HFOV?
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Chest expansion of 8.5 to 9 ribs
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Amplitude is most like what parameter in conventional MV
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Tidal volume; creates depth of wave
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How is proper setting of amplitude determined
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chest wiggle; thorax from the n ipple line to the umbilicus
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What is a good initial amplitude setting; how are changes made
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2 cmH2O then adjust by 1-2 cmH2O; readjustment of MAP
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What parameter in HFOV is similar to rate in conventional ventilation
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Frequency (measured in Hz)
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How is the exact Hz rate calculated
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Hz x 60 = actual Hz
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When the freqency is changed, what other parameters are dramatically affected
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Amplitude & MAP
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What parameter in HFOV is most like PIP
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MAP
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What should the MAP initially be set at in HFOV
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Initial MAP in HFOV:
2-4 cmH2O over PIP (from conventional MV) |
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Definition of Optimal Pressure
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amount of P needed to ventilate adequately & maintain a normal PaCO2
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Parameters for HFOV when changing over from conventional MV
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MAP - 2-4 cmH2O over PIP
amplitude - chest wiggle Hz as table suggests FiO2: 100% CXR w/in 30-60 min rib expansion - 8.5-9 ribs ABG's to monitor progress |
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4 P's that indicate translaryngeal intubation
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Pulmonary Function
Provide an airway Protect the airway Pulmonary Hygiene |
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Define acute ventilatory dysfunction
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PaCO2 > 50-60 mmHg &
pH < 7.3 |
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Define pulmonary dysfunction due to hypoxemia
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PaO2 < 60 mmHg w/FiO2 of .60 or more
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MSMAID
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Monitors
Suction Machine Airway Intravenous Drugs |
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Pediatric Endotracheal tube size and cuff pressure limit
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sizes 2.5 to 4.0 used in kids
20 cmH2O optimal cuff P |
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How is proper ET tube size for toddlers or small children
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lip to tip formula
ETT position (cm) = 12 + age in yr. divided by 2 |
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What is vacuum P for the neonate and for the pediatric patient
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neonate 60-80 mmHg
pediatric 80-100 mmHg |
