Mechanical Ventilation for Nursing

5/28/2018 Mechanical Ventilation for Nursing

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Mechanical Ventilation

for Nursing

Melissa Dearing, BS, RRT-NPS, RCP

Associate Professor of Respiratory Care

Curtis Shelley, BS, RRT-NPS, RCPRespiratory EducatorHermann Childrens Hospital


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Indications for

Mechanical Ventilation

Airway Compromiseairway

patency is in doubt or patient may

be at risk of losing patency


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Indications for Mechanical

Ventilation

Respiratory Failure2 Types

Hypoxemic Respiratory Failure

Hypercapnic Respiratory Failure


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Hypoxemic Respiratory

Failure

PaO2 < 60 mmHg in an

otherwise healthy individual


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Hypercapnic Respiratory

Failure

PaCO2> 50 mmHg in an otherwise

healthy individual

AKA Ventilatory Failure

Caused by increased WOB, ventilatory

drive, or muscle fatigue


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Indications for Mechanical

Ventilation

Need to Protect the Airway

For some reason the patients ability

to sneeze, gag or cough has been

dulled and aspiration is possible.


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Contraindications for an

Artificial Airway

When a pts desire to not be

resuscitated has been expressed

and is documented in the pts chart


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Establishing an Artificial

Airway

Adult female 8.0

Adult male 9.0


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Miller vs. MacIntosh Blades


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Intubation Procedure

Check and Assemble Equipment:

Oxygen flowmeter and O2tubing

Suction apparatus and tubingSuction catheter or yankauer

Ambu bag and mask

Laryngoscope with assorted blades

3 sizes of ET tubes

Stylet

Stethoscope

Tape

Syringe

Magill forceps

Towels for positioning


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Position your patient into the sniffing

position


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Preoxygenate with 100% oxygen to

provide apneic or distressed patient

with reserve while attempting to

intubate.

Do not allow more than 30 seconds to

any intubation attempt.

If intubation is unsuccessful, ventilate

with 100% oxygen for 3-5 minutes

before a reattempt.


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Insert Laryngoscope


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After displacing the epiglottis

insert the ETT.

The depth of the tube for a male

patient on average is 21-23 cm at teeth

The depth of the tube on average for a

female patient is 19-21 at teeth.


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Confirm tube position:

By auscultation of the chest

Bilateral chest rise

Tube location at teethCO2 detector(esophageal

detection device)


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Stabilize the ETT


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Video on Intubation:

http://youtube.com/watch?v=eRkleyIJi9U&fe

ature=related
http://youtube.com/watch?v=eRkleyIJi9U&feature=relatedhttp://youtube.com/watch?v=eRkleyIJi9U&feature=relatedhttp://youtube.com/watch?v=eRkleyIJi9U&feature=relatedhttp://youtube.com/watch?v=eRkleyIJi9U&feature=related


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Mechanical Ventilators

Different Types of Ventilators

Available:

Will depend on you place of

employment


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High Frequency Mechanical

Ventilator


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Ventilator Settings

Terminology

A/C: Assist-Control

IMV: Intermittent Mandatory VentilationSIMV: Synchronized Intermittent

Mandatory Ventilation

Bi-level/Biphasic: Non-inversedPressure Ventilation with Pressure

Support (consists of 2 levels of pressure)


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Ventilator Settings

Terminology (cont)

PRVC: Pressure Regulated Volume

Control

PEEP: Positive End Expiratory Pressure

CPAP: Continuous Positive Airway

Pressure

PSV: Pressure Support Ventilation

NIPPV: Non-Invasive Positive Pressure

Ventilation


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VOLUME vs. PRESSURE

VENTILATION

Volume ventilation: Volume is

constant and pressure will vary withpatients lung compliance.

Pressure ventilation: Pressure is

constant and volume will vary withpatients lung compliance.


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MODES of VENTILATION


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Control Mode

Delivers pre-set volumes at a pre-set

rate and a pre-set flow rate.

The patient CANNOT generate

spontaneous breaths, volumes, or flowrates in this mode.


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Control Mode


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Assist/Control Mode

Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.

The patient CANNOT generatespontaneous volumes, or flow ratesin this mode.

Each patient generated respiratory

effort over and above the set rateare delivered at the set volume andflow rate.


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A/C cont.

Negative deflection,

triggering assisted

breath


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Delivers a pre-set number of breaths at a

set volume and flow rate.Allows the patient to generate

spontaneous breaths, volumes, and flow

rates between the set breaths.Detects a patients spontaneous breath

attempt and doesnt initiate a ventilatory

breathprevents breath stacking

SYCHRONIZED

INTERMITTENT MANDATORY

VENTILATION (SIMV):


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SIMV cont.

Machine BreathsSpontaneous Breaths


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PRESSURE REGULATED

VOLUME CONTROL (PRVC):

This is a volume targeted, pressurelimited mode. (available in SIMV orAC)

Each breath is delivered at a setvolume with a variable flow rate and

an absolute pressure limit. The vent delivers this pre-set volume

at the LOWEST required peakpressure and adjust with each breath.


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PRVC

POSITIVE END


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POSITIVE END

EXPIRATORY PRESSURE

(PEEP):

This is NOT a specific mode, but is rather anadjunct to any of the vent modes.

PEEP is the amount of pressure remaining inthe lung at the END of the expiratory phase.

Utilized to keep otherwise collapsing lungunits open while hopefully also improvingoxygenation.


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PEEP cont.

PEEP is theamount of

pressure

remaining in the

lung at the END

of the expiratory

phase.

Pressure above zero


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Demonstration of PEEP

http://youtube.com/watch?v=oKH7CtsEgH

w
http://youtube.com/watch?v=oKH7CtsEgHwhttp://youtube.com/watch?v=oKH7CtsEgHwhttp://youtube.com/watch?v=oKH7CtsEgHwhttp://youtube.com/watch?v=oKH7CtsEgHw


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Continuous Positive Airway

Pressure (CPAP):

This IS a mode and simply means that a pre-set pressure is present in the circuit and

lungs throughout both the inspiratory andexpiratory phases of the breath.

CPAP serves to keep alveoli from collapsing,resulting in better oxygenation and less

WOB. The CPAP mode is very commonly used as a

mode to evaluate the patients readiness forextubation.


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HIGH FREQUENCY

VENTILATION


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Comparison of HFOV

& Conventional Ventilation

Differenc es CMV HFOV

Rates 0 - 150 180 - 900

Tidal Volume 4 - 20 ml/kg 0.1 - 3 ml/kg

Alveolar Press 0 - > 50 cmH2O 0.1 - 5 cmH2O

End Exp Volume Low Normalized

Gas Flow Low High


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Oxygenation

Oxygenation is primarily controlled by the

Mean Airway Pressure (Paw) and the FiO2.

Mean Airway Pressure is a constant pressure

used to inflate the lung and hold the alveoli

open.

Since the Paw is constant, it reduces theinjury that results from cycling the lung open

for each breath


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Video on HFOV

http://youtube.com/watch?v=jLroOPoPlig
http://youtube.com/watch?v=jLroOPoPlighttp://youtube.com/watch?v=jLroOPoPlig


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Initial Settings

Select your mode of ventilation

Set sensitivity at Flow trigger mode

Set Tidal Volume

Set Rate

Set Inspiratory Flow (if necessary)

Set PEEP Set Pressure Limit

Humidification


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Post Initial Settings

Obtain an ABG (arterial blood gas)

about 30 minutes after you set your

patient up on the ventilator.

An ABG will give you information about

any changes that may need to be made

to keep the patients oxygenation and

ventilation status within a physiologicalrange.


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ABG

Goal:

Keep patients acid/base balance within

normal range:

pH 7.357.45

PCO2 35-45 mmHg

PO2 80-100 mmHg


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TROUBLESHOOTING


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TROUBLESHOOTING

Anxious Patient

Can be due to a malfunction of the ventilator

Patient may need to be suctioned

Frequently the patient needs medication for anxietyor sedation to help them relax

Attempt to fix the problem

Call your RT


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Low Pressure Alarm

Usually due to a leak in the circuit.

Attempt to quickly find the problem

Bag the patient and call your RT.


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High Pressure Alarm

Usually caused by:

A blockage in the circuit (water

condensation)

Patient biting his ETT

Mucus plug in the ETT

You can attempt to quickly fix the

problem

Bag the patient and call for your RT.


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Low Minute Volume Alarm

Usually caused by:

Apnea of your patient (CPAP)

Disconnection of the patient fromthe ventilator

You can attempt to quickly fix the

problem Bag the patient and call for your

RT.


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Accidental Extubation

Role of the Nurse:

Ensure the Ambu bag is attached to theoxygen flowmeter and it is on!

Attach the face mask to the Ambu bagand after ensuring a good seal on thepatients face; supply the patient withventilation.

Bag the patient and call foryour RT.


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OTHER

Anytime you have concerns,alarms, ventilator changes or any

other problem with yourventilated patient.

Call for your RT

NEVER hit the silencebutton!

Mechanical Ventilation for Nursing

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