Transcript tf2 - Webnetworks MD
Respiratory Calculations
• • • • • Gas Laws Oxygen therapy Humidity Ventilator Management Hemodynamics
Gas Laws
• • • • • • Dalton’s Law Fick’s Law of Diffusion Boyle’s Law, Charles Law, Gay-Lussac’s Combined Gas Law Graham’s Law Poiseuille’s Law Temperature Conversion (C to F and vice versa)
Oxygen Therapy
• • • • • • • Total Flow Tank Duration Arterial & Venous O2 Content [C(a-v)O2] difference Alveolar Air Equation P(A-a) O2 Gradient Heliox flow rates
Total Flow
100 Subtract FiO2 - 20 (or 21) If the FiO2 Is .40 or > Use 20 (< .40 Use 21) 20 or 21 FiO2 Subtract 100 - FiO2 These 2 values Will Determine the Air: O2 ratio
Add the numbers of the ratio X flow rate = Total flow
Total Flow: Example
100 A COPD patient is currently on a 40% aerosol face mask running at 10 LPM. Calculate the total flow.
20 1 40 (1 + 3) x 10 = 40 LPM 20 60 3
Tank Duration
E cylinder: .28
H cylinder: 3.14
Pressure of the cylinder
PSIG x Tank factor Flow rate
The flow the O2 Device is set at
Tank Duration: Example
A patient is currently on a 4 L nasal cannula. The patient needs to be transported using an E cylinder. The E cylinder reads 2200 psig on the Bourdon gauge. According to hospital policy, the tank should not be used once the pressure reading reaches 200 psig. Calculate how long the tank will last (2200-200) x .28
4 152.6 minutes 60 min/hr 2.54 Hours
Arterial & Venous O2 Content
Arterial and venous. O2 content represents the amount of oxygen that is bound to hemoglobin
and
dissolved in the blood. The difference is that arterial O2 content represents the arterial system (high O2), and venous O2 content represents the venous system (low O2).
C x O2 = (1.34 x Hgb x S x O2) + (P x O2 x .003)
O2 carried/bound to hemoglobin O2 dissolved in blood plasma
Comparison of CaO2 & CvO2
Arterial O2 Content C a O2 = (1.34 x Hgb x S a O2) + (P a O2 x .003)
A constant Hemoglobin Arterial saturation Partial Pressure Of arterial O2 A constant
Venous O2 Content C v O2 = (1.34 x Hgb x S v O2) + (P v O2 x .003)
Venous saturation Partial Pressure Of venous O2
Arterial O2 Content: Example
Given the following values, calculate the CaO2: PaO2 = 93 mmHg PvO2 = 47 mmHg SaO2 = 98% SvO2 = 77% Hemoglobin = 16 g/dL CaO2 = (1.34 x 16 x .98) + (93 x .003) CaO2 = 21.01 + .279 =
21.29 vol %
Normal value for CaO2 is approximately 20 vol %
Venous O2 Content: Example
Given the following values, calculate the CvO2: PaO2 = 93 mmHg PvO2 = 47 mmHg SaO2 = 98% SvO2 = 77% Hemoglobin = 16 g/dL CvO2 = (1.34 x 16 x .77) + (47 x .003) CvO2 = 16.51 + .141 =
16.65 vol %
Normal CvO2 is approximately 15 vol %
C(a-v) Difference
The C(a-v) difference represents the difference between arterial And venous oxygen content. It is a reflection of oxygen Consumption (oxygen used by tissues within the body) Recall the values from the 2 previous examples: CaO2 = 21.29 vol % CvO2 = 16.65 vol % To determine the C(a-v)O2, simply subtract:
CaO2 - CvO2
21.29 - 16.65 =
4.64 vol %
Normal C(a-v)O2 = 5 vol %
C(a-v) difference: Clinical Info
C(a-v)O2 can be an important clinical indicator. Recall that The C(a-v)O2 reflects the amount of oxygen taken from arterial Blood to be used by body tissues. Refer to the diagram below: Arterial: CaO2 = 20 vol% Arterial blood contains Approx 5 vol% of O2 O 2 O 2 O 2 Tissues O 2 5 vol% of O2 Is extracted from Arterial blood Venous: CvO2 = 15 vol% O2 that is NOT extracted From arterial blood enters Venous circulation
C(a v) Difference con’t…
When blood flows through the body at a normal rate, approximately 5 vol% of the O2 present in arterial blood is extracted by the tissues.
The remaining O2 enters the venous system.
When blood flows through the body slower than normal, blood begins To pool and more O2 is taken from arterial blood. With the tissues Extracting more O2, less O2 is present in the venous system. If you Have a lower venous O2 content, and subtract it from the CaO2, you Get a greater C(a-v)O2 difference
An increase in the C(a-v)O2 difference = a decrease in cardiac output
Alveolar Air Equation
The Alveolar air equation represents the partial Pressure of oxygen in the alveoli A/C This is what we Are finding using The alveolar Air equation P
a
O2 P
A
O2 O2 O2 O2 O2
diffusion
O2 O2 O2 O2 Alveolus Capillary M E M B R A N E
Alveolar Air Equation: Con’t…
P A O2 = [(P B -P H2O ) FiO2] - P a CO 2 / .8
O2 concentration Barometric pressure Normal is 760 mmHg Water pressure Constant: 47 mmHg Arterial CO2 Constant: Respiratory Quotient CO2 removed/O2 consumed 200 mL/ 250 mL = .8
Alveolar Air Equation: Example
Given the following information, calculate the P A O2 PB = 760 mmHg FiO2 = .60
PaCO2 = 40 mmHg PaO2 = 88 mmHg Hgb = 14 g/dL PAO2 = [(760 - 47).60] - 40 / .8 =
377.8 mmHg
P(A-a)O2 Gradient
P(A-a)O2 represents the difference between the partial pressure Of O2 in the alveoli and the partial pressure of O2 in the arteries.
In other words, it reflects how much of the available O2 (PAO2) Is actually diffusing into the blood (PaO2). In a healthy individual, the P(A-a)O2 should be very small. In other words, the majority of the available O2 is diffusing Into the blood
(refer to the diagram on the “alveolor air Equation slide for a better understanding)
If the P(A-a)O2 increases, it signals there is some problem with the gas diffusion mechanism (shunting for example).
P(A-a)O2 Gradient: Example
Using the PAO2 calculated earlier (377.8 mmHg), calculate The P(A-a)O2 if the PaO2 is 80 mmHg P(A-a)O2 = 377.8 - 80
297.8 mmHg
What does this number tell you?
This number indicates that a significant amount of the available O2 is not diffusing into the blood, indicating a shunt is present
Heliox Flow Rates
Heliox is a mixture of helium and oxygen. Because helium is less Dense than oxygen, it is used to carry oxygen past airway Obstructions. Because heliox is less dense than pure oxygen, It has a faster flow.
2 different heliox mixtures:
Multiply flow Reading by A factor of 1.8
To get actual flow Helium : Oxygen 80 : 20 70 : 30 Multiply flow Reading by A factor of 1.6 to Get actual flow
Heliox Flow Rates: Example
A physician orders 80:20 heliox to be run at 18 LPM. At what flow rate should the flow meter be set?
We know that
Set Flow rate x 1.8 = actual flow of 80:20 heliox
We can rearrange this equation to solve for the set flow rate: Set flow rate = Actual flow / 1.8
Set flow rate = 18 LPM / 1.8
Set flow rate = 10 LPM In order to have an actual flow of 18 LPM, we need to set the Flow meter at 10 LPM (If this were a 70:30 mixture, replace 1.8 with 1.6)
Humidity
• Body Humidity
Body Humidity
Normal body humidity is expressed as
44 mg/L
or
47 mmHg
This means that at 98.6 F (37 C) gas is saturated with 44 mgHg or 44 mg/L of water vapor
Relative Humidity:
What is the relative humidity Of a gas saturated with 30 mg/L Of water at body temperature?
30 mg/L 44 mg/L = 68%
Humidity Deficit:
What is the humidity deficit Of a gas saturated at 30 mg/L Of water at body temperature?
44 mg/L - 30 mg/L =
14 mg/L
Ventilator Management
• • • • • • • • Compliance (dynamic vs. static) Resistance I-time, peak flow rate, vt I:E ratio Desired CO2 / VE Desired PaO2 VD/VT Minute Ventilation / Alveolar Ventilation
Compliance
Generic Equation
∆ Volume ∆ Pressure Pressure Or volume Dynamic Static Graph of Mechanical Breath PIP(dyna mic pressure) Plateau pressure Insp . Hold PEEP chang e-over from insp to exp NEEP I-Tim e E-Time
Dynamic Compliance
Tidal Volume (mL) Peak Pressure - PEEP
Dynamic compliance measures the elasticity of the lung During air movement. It is a less reliable indicator of lung Elasticity compared to static compliance
Note: Peak Pressure = PIP
Static Compliance
Tidal Volume (mL) Plateau Pressure - PEEP
Static compliance measures the elasticity of the lung When there is no air movement. It is the best indicator Of the ability to ventilate the lungs.
Normal static compliance is: 60 - 70 mL/cmH2O
Note: Plateau pressure = PPL = Static Pressure
Understanding Compliance
∆ Volume ∆ Pressure mL cmH2O Compliance tells that for every1 cmH2O pressure the lungs Can hold
X
mL of air.
The more mL of air that a lung can hold Per cmH2O, the more compliant the lung.
Example:
Patient A: 30 mL/cmH2O Patient B: 60 mL/cmH2O Patient B has more compliant lungs. Patient A’s lungs Can only hold 30 mL of air for every cmH2O of pressure, Whereas patient B can hold 60 mL of air for every cmH2O.
Compliance Example 1
Calculate the static compliance given the following Information: FiO2: .60 Rate: 12 bpm Peak Pressure: 38 cmH2O Plateau Pressure: 29 cmH2O Vt: 600 mL PEEP: +5 cmH2O Vt PPL - PEEP 600 29 - 5
25 mL/cmH2O
Compliance Example 2
Calculate the static compliance given the following Information: FiO2: .60 Rate: 12 bpm Peak Pressure: 38 cmH2O Plateau Pressure: 29 cmH2O Vt: 600 mL PEEP: +5 cmH2O Vt PIP - PEEP 600 38 - 5
18.18 mL/cmH2O
Compliance Clinical Scenario
Plateau Pressure: PEEP:
Mr. J arrived to the ER in acute respiratory distress. He was Subsequently intubated and placed on mechanical ventilation In the ICU. Reviewing Mr. J’s ventilator sheet reveals the Following information:
Tidal Volume: 8:00 a.m.
22 cmH2O 5 cmH2O 600 mL
12:00 p.m.
27 cmH2O 5 cmH2O 600 mL
4:00 a.m.
31 cmH2O 5 cmH2O 600 mL What does the information reveal about the compliance of Mr. J’s lungs?
Compliance Clinical Scenario
600 mL 22 cmH2O - 5 cmH2O 600 mL 27 cmH2O - 5 cmH2O 600 mL 31 cmH2O - 5 cmH2O
35.29 mL/cmH2O 27.27 mL/cmH2O 23.08 mL/cmH2O Compliance is decreasing --> Increasing static pressure results In a decreased compliance
Airway Resistance (Raw)
Airway resistance measures the force that
opposes
Through the airway gas flow
Normal airflow Increased Raw
Normal Raw is 0.6 - 2.4 cmH2O/L/Sec on a non-intubated Patient, and 5 cmH2O/L/Sec on an intubated patient
Airway Resistance (Raw)
Peak Pressure - Plateau Pressure Flow
Flow must be in Divide the flow by 60 seconds before placing It in the equation
L/sec.
If flow is given in L/min, Example: Convert 60 L/min to L/sec 60 L/min 60
1 L/sec
Airway Resistance Example
Calculate the airway resistance, given the following FiO2: .60 Rate: 12 bpm Peak Pressure: 38 cmH2O Plateau Pressure: 29 cmH2O Vt: 600 mL PEEP: +5 cmH2O Flow: 40 LPM 1st convert the flow 40 LPM 60 .67 L/sec PIP - PPL Flow 38 - 29 .67
13.43 cmH2O/L/Sec
I-time, Peak flow, Vt
The following generic equation can be used to find I-time, peak flow rate, and tidal volume
Tidal Volume (in L) I-time = Peak Flow(LPM) 60
Finding I-time
I-time is the inspiratory portion of a breath. In other words, It is the amount of time spent on inspiration I-time E-time
To find I-time 1st: determine the length of a single breath 2nd: Use the I:E ratio to determine the length of the I-time
I-Time Example
Calculate the I-time given the following ventilator parameters Vt: 600 cc Peak Flow: 60 LPM I:E = 1:2 FiO2: .60
Rate: 12 bmp
1st: determine the length of a single breath
There are 12 breaths in 1 minute and 60 seconds in 1 minute.
Therefore 60 seconds / 12 breaths =
1 breath every 5 seconds
Therefore, then legnth of 1 breath is 5 seconds
2nd: Use the I:E ratio to determine the length of the I-time
1x + 2x = 5 3x = 5 X = 5/3 or 1.67
1x equals the inspiratory portion of the Breath. 1 x 1.67 =
1.67 seconds
Finding Peak Flow
Find the peak flow, given the following V T = 750 cc RR = 15 I:E = 1:2.5
First find the I-time (see the previous slide):
1.14 sec
Tidal Volume (in L) I-time .750
1.14
= = Peak Flow(LPM) 60 X 60 (.750)60 = 1.14X
45 1.14
39.47 LPM
Finding Vt
Find the Vt given the following: PF = 50 LPM, RR = 14, I:E = 1:2 First, Find the I-time:
1.43 sec
Tidal Volume (in L) I-time X 1.43
= = Peak Flow(LPM) 60 50 60 (1.43)50 = 60X 60X 71.5
X = 1.1917 L or 1191.7 mL
I:E Ratio
Determine the I:E ratio for a patient on a ventilator breathing 20 bpm, Vt: 600 cc, Peak flow of 50 LPM.
1st, find the I-time:
Tidal Volume (in L) I-time . 6 X = Peak Flow(LPM) 60 = 50 60
.72 seconds 2nd, Calculate the total breath time:
60 seconds 20
3 seconds
I:E Ratio
I-time: .72 seconds Total breath time: 5 seconds Remember that a total breath is composed of an inspiratory Time and expiratory time, therefore:
Total time - I-time = E-time
3 - .72 = 4.28
I-time : E-time .72 : 2.28
Convert to a 1:X ratio .72 : 2.28
.72
1 : 3.2
Achieving correct CO2/Minute ventilation
Current VE x Current PaCO2 Desired PaCO2
Example: The doctor wants to decrease a patients PaCO2 from 50 mmHg to 35 mmHg. The doctor wants your advice on a proper minute ventilation. The current settings include a rate of 12 and a tidal volume of 500 mL. Current VE = 12 x 500
= 6000 mL or 6 L
6L x 50 35
8.57 L
You would need to se the Ventilator with a rate and tidal Volume that equals 8.57 L.
(e.g. rate of 10, Vt of 857 mL)
Achieving correct PaO2
Desired PaO2 x FiO2 Current PaO2 Example:
A patient is currently hypoxic with a PaO2 Of 60 on an FiO2 of .45. The physician orders to maintain A PaO2 of at least 80 mmHg and asks you to adjust the Ventilator accordingly 80 mmHg x .45
60 mmHg
.60
Increase the FiO2 to .60 to achieve a PaO2 Of 80 mmHg
VD/Vt
The VD/Vt equation illustrates the % of gas that does not Participate in gas exchange. In other words, it reflects The % of gas that is
deadspace.
PaCO2 -PeCO2 PaCO2 Deadspace refers to ventilation in the absence of perfusion O2 O2 O2 O2 Alveoli capillary Blocked blood flow
VD/Vt example
Calculate the VD/Vt given the following: PaO2: 88 mmHg Vt: 550 mL PaCO2: 40 mmHg PeCO2: 31 mmHg PaCO2 -PeCO2 PaCO2 40 - 31 40
= 22.5%
To determine the actual volume Of deadspace, just multiply The % deadspace by the given Tidal volume: .225 x 550 =
123.75 mL
Normal deadspace: 20 - 40%, up to 60% on ventilator
Minute/Alveolar Ventilation
Minute ventilation refers the volume of gas inhaled during A 1 minute period.
Minute ventilation(VE) = Tidal volume x Respiratory rate
Normal Minute ventilation = 5 - 10 LPM
Alveolar ventilation
refers the the volume of gas that actually Participates in gas exchange.
Alveolar ventilation = (tidal volume - deadspace) x RR 1 mL/lb of body weight Or 1/3 of tidal volume
Example
Calculate the alveolar minute ventilation for a 150 lb male With a respiratory rate of 18 and tidal volume of 500 mL Alveolar ventilation = (500 - 150) x 18
= 6300 mL or 6.3 L
Hemodynamics
• • • • • • • • Shunt Pulmonary vascular resistance Systemic vascular resistance Mean pressure Pulse pressure Cardiac output (Fick's equation) Stroke Volume Cardiac Index