Mechanical ventilation ppt

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NURSING MANAGEMENT OF MECHANICALLY

VENTILATED PATIENTS

Presented ByBibini Baby 2nd year MSc. Nsg Govt. College of

NsgKottayam

Spontaneous respiration vs. Mechanical ventilation

• Natural Breathing– Negative inspiratory force– Air pulled into lungs

• Mechanical Ventilation– Positive inspiratory pressure– Air pushed into lungs

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Mechanical ventilation

• Negative pressure• Positive pressure Invasive Noninvasive

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Negative-Pressure Ventilators

• Early negative-pressure ventilators were known as “iron lungs.”

• The patient’s body was encased in an iron cylinder and negative pressure was generated

• The iron lung are still occasionally used today.

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• Intermittent short-term negative-pressure ventilation is sometimes used in patients with chronic diseases.

• The use of negative-pressure ventilators is restricted in clinical practice, however, because they limit positioning and movement and they lack adaptability to large or small body torsos (chests) .

• Our focus will be on the positive-pressure ventilators.

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POSITIVE PRESSURE VENTILATION (INVASIVE)

Initiation of Mechanical Ventilation

• Indications– Indications for Ventilatory Support

–Acute Respiratory Failure–Prophylactic Ventilatory Support–Hyperventilation Therapy

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• Indications– Acute Respiratory Failure (ARF)

• Hypoxic lung failure (Type I)– Ventilation/perfusion mismatch– Diffusion defect– Right-to-left shunt– Alveolar hypoventilation– Decreased inspired oxygen– Acute life-threatening or vital

organ-threatening tissue hypoxia9



• Acute Hypercapnic Respiratory Failure (Type II)– CNS Disorders

» Reduced Drive To Breathe: depressant drugs, brain or brainstem lesions (stroke, trauma, tumors), hypothyroidism

» Increased Drive to Breathe: increased metabolic rate (CO2 production), metabolic acidosis, anxiety associated with dyspnea

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• Acute Hypercapnic Respiratory Failure (Type II)– Neuromuscular Disorders

» Paralytic Disorders: Myasthenia Gravis, Guillain-Barre´11, poliomyelitis, etc.

» Paralytic Drugs: Curare, nerve gas, succinylcholine, insecticides

» Drugs that affect neuromuscular transmission; calcium channel blockers, long-term adenocorticosteroids, etc.

» Impaired Muscle Function: electrolyte imbalance, malnutrition, chronic pulmonary disease, etc. 11



• Acute Hypercapnic Respiratory Failure– Increased Work of Breathing

» Pleural Occupying Lesions: pleural effusions, hemothorax, empyema, pneumothorax

» Chest Wall Deformities: flail chest, kyphoscoliosis, obesity

» Increased Airway Resistance: secretions, mucosal edema, bronchoconstriction, foreign body

» Lung Tissue Involvement: interstitial pulmonary fibrotic diseases

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• Acute Hypercapnic Respiratory Failure– Increased Work of Breathing (cont.)

» Lung Tissue Involvement: interstitial pulmonary fibrotic diseases, aspiration, ARDS, cardiogenic PE, drug induced PE

» Pulmonary Vascular Problems: pulmonary thromboembolism, pulmonary vascular damage

» Dynamic Hyperinflation (air trapping)» Postoperative Pulmonary Complications

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Initiation of Mechanical Ventilation• Prophylactic Ventilatory Support

– Clinical conditions in which there is a high risk of future respiratory failure

• Examples: Brain injury, heart muscle injury, major surgery, prolonged shock, smoke injury

• Ventilatory support is instituted to:–Decrease the WOB–Minimize O2 consumption and hypoxemia–Reduce cardiopulmonary stress–Control airway with sedation 14


• Hyperventilation Therapy– Ventilatory support is instituted to control and

manipulate PaCO2 to lower than normal levels• Acute head injury

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Criteria for institution of ventilatory support:

Normal range

Ventilation indicated

Parameters

10-20

5-7

65-75

75-100

>35

<5

<15

-<20

A- Pulmonary function studies:

• Respiratory rate (breaths/min).• Tidal volume (ml/kg body wt)• Vital capacity (ml/kg body wt)• Maximum Inspiratory Force (cm HO2)

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Criteria for institution of ventilatory support:

Normal range

Ventilation indicated

Parameters

7.35-7.4575-10035-45

<7.25 <60 >50

B- Arterial blood Gases

• PH• PaO2 (mmHg)

• PaCO2 (mmHg)

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• Contraindications– Untreated pneumothorax

• Relative Contraindications– Patient’s informed consent– Medical futility– Reduction or termination of patient pain

and suffering

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Essential components in mechanical ventilation

• Patient • Artificial airway• Ventilator circuit• Mechanical ventilator• A/c or D/c power source• O2 cylinder or central oxygen supply

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Artificial airways

• Tracheal intubation– Nasal– Oral

• Supraglottic airway • Cricothyrotomy• Tracheostomy

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Laryngeal airway

Intubation ProcedureCheck and Assemble Equipment:

Oxygen flowmeter and O2 tubingSuction apparatus and tubingSuction catheterAmbu bag and maskLaryngoscope with assorted blades3 sizes of ET tubesStilletStethoscopeTapeSyringeSterile gloves

Intubation ProcedurePosition your patient into the sniffing position

Intubation Procedure

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.

Intubation Procedure Insert Laryngoscope


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.


Confirm tube position:

By auscultation of the chestBilateral chest riseTube location at teethCO2 detector – (esophageal detection device or by capnography)

Intubation Procedure Stabilize the ETT

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Ventilator circuit

• Breathing System Plain• Breathing System with Single Water Trap• Breathing System with Double Water Trap.• Breathing Filters HME Filter• Flexible Catheter Mount

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Ventilator circuit

Breathing system plain

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Ventilator Breathing System (1.6m)

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Ventilator Breathing System (1.6m)

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heat & moisture exchanger HME filter

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MECHANICAL VENTILATOR

• A mechanical ventilator is a machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilation.

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Types of Mechanical ventilators

• Transport ventilators • Intensive-care ventilators• Neonatal ventilators • Positive airway pressure ventilators for NIV

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Classification of positive-pressure ventilators

• Ventilators are classified according to how the inspiratory phase ends. The factor which terminates the inspiratory cycle reflects the machine type.

• They are classified as:

1- Pressure cycled ventilator

2- Volume cycled ventilator

3- Time cycled ventilator

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1- Volume-cycled ventilator

• Inspiration is terminated after a preset tidal volume has been delivered by the ventilator.

• The ventilator delivers a preset tidal volume (VT), and inspiration stops when the preset tidal volume is achieved.

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2- Pressure-cycled ventilator

• In which inspiration is terminated when a specific airway pressure has been reached.

• The ventilator delivers a preset pressure; once this pressure is achieved, end inspiration occurs.

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3- Time-cycled ventilator

• In which inspiration is terminated when a preset inspiratory time, has elapsed.

• Time cycled machines are not used in adult critical care settings. They are used in pediatric intensive care areas.

Mechanical VentilatorsDifferent Types of Ventilators Available:

Will depend on your place of employmentVentilators in use in MCHServo S by MaquetSavina by Drager

MODES OF VENTILATION

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Ventilator mode

• The way the machine ventilates the patient

• How much the patient will participate in his own ventilatory pattern.

• Each mode is different in determining how much work of breathing the patient has to do.

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A- Volume Modes

• 1. CMV or CV• 2. AMV or AV• 3. IMV• 4. SIMV

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B- Pressure Modes1- Pressure-controlled ventilation (PCV) 2- Pressure-support ventilation (PSV)

3- Continuous positive airway pressure (CPAP)

4- Positive end expiratory pressure (PEEP)

5- Noninvasive bilevel positive airway pressure ventilation (BiPAP)

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 flow rates in this mode.

Control Mode

Assist/Control Mode

•Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.•The patient CANNOT generate spontaneous volumes, or flow rates in this mode. •Each patient generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.

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Assist Control

• Volume or Pressure control mode• Parameters to set:

– Volume or pressure– Rate – I – time– FiO2

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Assist Control

• Machine breaths: – Delivers the set volume or pressure

• Patient’s spontaneous breath: – Ventilator delivers full set volume or pressure &

I-time• Mode of ventilation provides the most

support

Negative deflection, triggering assisted breath

Assist Control

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 patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking

SYCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV):

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SIMV Synchronized intermittent mandatory ventilation

• Machine breaths: – Delivers the set volume or pressure

• Patient’s spontaneous breath:– Set pressure support delivered

• Mode of ventilation provides moderate amount of support

• Works well as weaning mode

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SIMV cont.

Machine BreathsSpontaneous Breaths

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IMV

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical Care

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Volume Modes

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PRESSURE REGULATED VOLUME CONTROL (PRVC):

• This is a volume targeted, pressure limited mode. (available in SIMV or AC)

• Each breath is delivered at a set volume with a variable flow rate and an absolute pressure limit.

• The vent delivers this pre-set volume at the LOWEST required peak pressure and adjust with each breath.

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PRVC (Pressure regulated volume control)

A control mode, which delivers a set tidal volume with each breath at the lowest possible peak pressure.

Delivers the breath with a decelerating flow pattern that is thought to be less injurious to the lung…… “the guided hand”.

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PRCV: Advantages

Decelerating inspiratory flow pattern

Pressure automatically adjusted for changes in compliance and resistance within a set rangeTidal volume guaranteedLimits volutraumaPrevents hypoventilation

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PRVC: DisadvantagesPressure delivered is dependent on tidal volume achieved on

last breathIntermittent patient effort variable tidal volumes

Pre

ssure

Flow

Volu

me

Set tidal volume

© Charles Gomersall 2003

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Pre

ssure

Flow

Volu

me

Set tidal volume

PRVC: DisadvantagesPressure delivered is dependent on tidal volume achieved on

last breathIntermittent patient effort variable tidal volumes

© Charles Gomersall 2003

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PRVC

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POSITIVE END EXPIRATORY PRESSURE (PEEP):

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

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

• Utilized to keep otherwise collapsing lung units open while hopefully also improving oxygenation.

• Usually, 5-10 cmH2O

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Pplat• Measured by occluding the ventilator 3-5 sec at

the end of inspiration• Should not exceed 30 cmH2O

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Peak Pressure (Ppeak)• Ppeak = Pplat + Pres

Where Pres reflects the resistive element of the respiratory system (ET tube and airway)

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Ppeak• Pressure measured at the end of inspiration

• Should not exceed 50cmH2O?

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Auto-PEEP or Intrinsic PEEP

– Normally, at end expiration, the lung volume is equal to the FRC

– When PEEPi occurs, the lung volume at end expiration is greater than the FRC

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• Why does hyperinflation occur?

– Airflow limitation because of dynamic collapse– No time to expire all the lung volume (high RR or

Vt)– Decreased Expiratory muscle activity– Lesions that increase expiratory resistance

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• Adverse effects:

– Predisposes to barotrauma– Predisposes hemodynamic compromises– Diminishes the efficiency of the force generated by

respiratory muscles– Augments the work of breathing– Augments the effort to trigger the ventilator

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• This is a mode and simply means that a pre-set pressure is present in the circuit and lungs throughout both the inspiratory and expiratory 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 for extubation.

Continuous Positive Airway Pressure (CPAP):

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Combination “Dual Control” Modes

Combination or “dual control” modes combine features of pressure and volume targeting to accomplish ventilatory objectives which might remain unmet by either used independently.

Combination modes are pressure targetedPartial support is generally provided by pressure support

Full support is provided by Pressure Control

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Combination “Dual Control” Modes Volume Assured Pressure Support

(Pressure Augmentation)

Volume Support

(Variable Pressure Support)

Pressure Regulated Volume Control

(Variable Pressure Control, or Autoflow)

Airway Pressure Release

(Bi-Level, Bi-PAP)

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• Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to, or longer than, expiratory time (1:1 to 4:1).

• Inverse I:E ratios are used in conjunction with pressure control to improve oxygenation by expanding stiff alveoli by using longer distending times, thereby providing more opportunity for gas exchange and preventing alveolar collapse.

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• As expiratory time is decreased, one must monitor for the development of hyperinflation or auto-PEEP. Regional alveolar overdistension and

barotrauma may occur owing to excessive total PEEP.

• When the PCV mode is used, the mean airway and intrathoracic pressures rise, potentially resulting in a decrease in cardiac output and oxygen delivery. Therefore, the patient’s hemodynamic status must be monitored closely.

• Used to limit plateau pressures that can cause barotrauma & Severe ARDS

HIGH FREQUENCY OSCILLATORY VENTILATION

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HIFI - Theory

• Resonant frequency phenomena:– Lungs have a natural resonant frequency– Outside force used to overcome airway resistance

• Use of high velocity inspiratory gas flow: reduction of effective dead space

• Increased bulk flow: secondary to active expiration

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HIFI - Advantages

• Advantages:– Decreased barotrauma / volutrauma: reduced swings

in pressure and volume– Improve V/Q matching: secondary to different flow

delivery characteristics• Disadvantages:

– Greater potential of air trapping– Hemodynamic compromise– Physical airway damage: necrotizing tracheobronchitis– Difficult to suction– Often require paralysis

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HIFI – Clinical Application

• Adjustable Parameters– Mean Airway Pressure: usually set 2-4 higher

than MAP on conventional ventilator– Amplitude: monitor chest rise– Hertz: number of cycles per second– FiO2– I-time: usually set at 33%

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Comparison of HFOV& Conventional Ventilation

Differences 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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Video on HFOV

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

http://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• Inspiratory time• Fraction of inspired oxygen

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TriggerThere are two ways to initiate a ventilator-delivered

breath: pressure triggering or flow-by triggeringWhen pressure triggering is used, a ventilator-delivered

breath is initiated if the demand valve senses a negative airway pressure deflection (generated by the patient trying to initiate a breath) greater than the trigger sensitivity.

When flow-by triggering is used, a continuous flow of gas through the ventilator circuit is monitored. A ventilator-delivered breath is initiated when the return flow is less than the delivered flow, a consequence of the patient's effort to initiate a breath

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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 patient’s oxygenation and ventilation status within a physiological range.

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ABG

• Goal:• Keep patient’s acid/base balance within

normal range:

• pH 7.35 – 7.45• PCO2 35-45 mmHg• PO2 80-100 mmHg

Initiation of Mechanical Ventilation• Initial Ventilator Settings

– Tidal Volume• Spontaneous VT for an adult is 5 – 7 ml/kg of IBW

Determining VT for Ventilated Patients• A range of 6 – 12 ml/kg IBW is used for adults

– 10 – 12 ml/kg IBW (normal lung function)– 8 – 10 ml/kg IBW (obstructive lung disease)– 6 – 8 ml/kg IBW (ARDS) – can be as low as 4 ml/kg

• A range of 5 – 10 ml/kg IBW is used for infants and children

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• Initial Ventilator Settings– Respiratory Rate

• Normal respiratory rate is 12-18 breaths/min.

• A range of 8 – 12 breaths per minute (BPM)Rates should be adjusted to try and minimize auto-

PEEP

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• Initial Ventilator Settings– Minute Ventilation

• Respiratory rate is chosen in conjunction with tidal volume to provide an acceptable minute ventilation

= VT x f

• Normal minute ventilation is 5-10 L/min• Estimated by using 100 mL/kg IBW• ABG needed to assess effectiveness of initial settings

– If PaCO2 >45 ( minute ventilation via f or VT)– If PaCO2 <35 ( minute ventilation via f or VT)

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– Inspiratory Flow • Rate of Gas Flow

– As a beginning point, flow is normal set to deliver inspiration in about 1 second (range 0.8 to 1.2 sec.), producing an I:E ratio of approximately 1:2 or less (usually about 1:4)

– This can be achieved with an initial peak flow of about 60 L/min (range of 40 to 80 L/min)

Most importantly, flows are set to meet a patient’s inspiratory demand

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Expiratory Flow PatternExpiratory Flow Pattern

Inspiration

Expiration

Time (sec)

Flo

w (

L/m

in)

Beginning of expirationexhalation valve opens

Peak Expiratory Flow RatePEFR

Duration of expiratory flow

Expiratory timeTE


– Flow Patterns• Selection of flow pattern and flow rate may depend on

the patient’s lung condition, e.g., – Post – operative patient recovering from anesthesia

may have very modest flow demands– Young adult with pneumonia and a strong

hypoxemic drive would have very strong flow demands

– Normal lungs: Not of key importance

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– Flow Pattern• Constant Flow (rectangular or square waveform)

– Generally provides the shortest TI– Some clinician choose to use a constant (square) flow

pattern initially because it enables them to obtain baseline measurements of lung compliance and airway resistance

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– Flow Pattern• Sine Flow

– May contribute to a more even distribution of gas in the lungs

– Peak pressures and mean airway pressure are about the same for sine and square wave patterns

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• Initial Ventilator Settings– Flow Pattern

• Descending (decelerating) Ramp– Improves distribution of ventilation, results in a longer TI,

decreased peak pressure, and increased mean airway pressure (which increases oxygenation)

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– Positive End Expiratory Pressure (PEEP)• Initially set at 3 – 5 cm H2O

– Restores FRC and physiological PEEP that existed prior to intubation

– Subsequent changes are based on ABG results

• Useful to treat refractory hypoxemia• Contraindications for therapeutic PEEP (>5 cm H2O)

– Hypotension– Elevated ICP– Uncontrolled pneumothorax

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– FiO2• Initially 100%

– Severe hypoxemia– Abnormal cardiopulmonary functions

» Post-resuscitation» Smoke inhalation» ARDS

• After stabilization, attempt to keep FiO2 <50%– Avoids oxygen-induced lung injuries

» Absorption atelectasis» Oxygen toxicity

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– FiO2 of 40% or Same FiO2 prior to mechanical ventilation

• Patients with mild hypoxemia or normal cardiopulmonary function

–Drug overdose–Uncomplicated postoperative recovery

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• Initial Ventilator Settings For PCV– Rate, TI, and I:E ratio are set in PCV as they are

in Volume mode– The pressure gradient (PIP-PEEP) is adjusted to

establish volume deliveryRemember: Volume delivery changes as lung characteristics change and can vary breath to breath

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• Initial Ventilator Settings For PCV– Flow Pattern

• PCV provides a descending ramp waveform

Note: The patient can vary the inspiratory flow on demand

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• Initial Ventilator Settings For PCV– Rise Time (slope, flow acceleration)

• Rise time is the amount of TI it takes for the ventilator to reach the set pressure at the beginning of inspiration

• Inspiratory flow delivery during PCV can be adjusted with an inspiratory rise time control

• Ventilator graphics can be used to set the rise time102

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● Sigh• A deep breath.

• A breath that has a greater volume than the tidal volume.

• It provides hyperinflation and prevents atelectasis.

• Sigh volume :------------------Usual volume is 1.5 –2 times tidal volume.

• Sigh rate/ frequency :---------Usual rate is 4 to 8 times per hour.

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Ensuring humidification and thermoregulation

• All air delivered by the ventilator passes through the water in the humidifier, where it is warmed and saturated or through an HME filter

• Humidifier temperatures should be kept close to body temperature 35 ºC- 37ºC.

• In some rare instances (severe hypothermia), the air temperatures can be increased.

• The humidifier should be checked for adequate water levels


• Ventilator Alarm Settings– High Minute Ventilation

• Set at 2 L/min or 10%-15% above baseline minute ventilation

– Patient is becoming tachypneic (respiratory distress)

– High Respiratory Rate Alarm• Set 10 – 15 BPM over observed respiratory rate

– Patient is becoming tachypneic (respiratory distress)

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• Ventilator Alarm Settings– Low Exhaled Tidal Volume Alarm

• Set 100 ml or 10%-15% lower than expired mechanical tidal volume

• Causes– System leak – Circuit disconnection– ET Tube cuff leak

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Initiation of Mechanical Ventilation• Ventilator Alarm Settings

– High Inspiratory Pressure Alarm• Set 10 – 15 cm H2O above PIP• Common causes:

– Water in circuit– Kinking or biting of ET Tube– Secretions in the airway– Bronchospasm– Tension pneumothorax– Decrease in lung compliance – Increase in airway resistance– Coughing

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• Ventilator Alarm Settings– Low Inspiratory Pressure Alarm

• Set 10 – 15 cm H2O below observed PIP• Causes

– System leak– Circuit disconnection– ET Tube cuff leak

– High/Low PEEP/CPAP Alarm (baseline alarm)• High: Set 3-5 cm H2O above PEEP

– Circuit or exhalation manifold obstruction– Auto – PEEP

• Low: Set 2-5 cm H2O below PEEP– Circuit disconnect

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• Ventilator Alarm Settings– High/Low FiO2 Alarm

• High: 5% over the analyzed FiO2• Low: 5% below the analyzed FiO2

– High/Low Temperature Alarm• Heated humidification

– High: No higher than 37 C– Low: No lower than 30 C

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• Ventilator Alarm Settings– Apnea Alarm

• Set with a 15 – 20 second time delay• In some ventilators, this triggers an apnea

ventilation mode– Apnea Ventilation Settings

• Provide full ventilatory support if the patient become apneic

• VT 8 – 12 mL/kg ideal body weight• Rate 10 – 12 breaths/min• FiO2 100%

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TROUBLESHOOTING

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Trouble Shooting the Vent

• Common problems– High peak pressures– Patient with COPD– Ventilator asynchrony – ARDS

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• If peak pressures are increasing:– Check plateau pressures by allowing for an

inspiratory pause (this gives you the pressure in the lung itself without the addition of resistance)

– If peak pressures are high and plateau pressures are low then you have an obstruction

– If both peak pressures and plateau pressures are high then you have a lung compliance issue

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• High peak pressure differential:High Peak PressuresLow Plateau Pressures

High Peak PressuresHigh Plateau Pressures

Mucus Plug ARDS

Bronchospasm Pulmonary Edema

ET tube blockage Pneumothorax

Biting ET tube migration to a single bronchus

Effusion

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COPD • If you have a patient with history of COPD/asthma with worsening

oxygen saturation and increasing hypercapnia differential includes:

– Must be concern with breath stacking or auto- PEEP

– Low VT with increased exhalation time is advisable

• Baseline ABGs reflect an elevated PaCO2 should not

hyperventilated. Instead, the goal should be restoration of the baseline PaCO2.

• These patients usually have a large carbonic acid load, and lowering their carbon dioxide levels rapidly may result in seizures.

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COPD and Asthma• Goals:

– Diminish dynamic hyperinflation– Diminish work of breathing– Controlled hypoventilation (permissive

hypercapnia)

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• Increase in patient agitation and dis-synchrony on the ventilator:– Could be secondary to overall discomfort

• Increase sedation

– Could be secondary to feelings of air hunger• Options include increasing tidal volume, increasing flow

rate, adjusting I:E ratio, increasing sedation

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Trouble shooting the vent

• If you are concern for acute respiratory distress syndrome (ARDS)– Correlate clinically with radiologic findings of

diffuse patchy infiltrate on CXR– Obtain a PaO2/FiO2 ratio (if < 200 likely ARDS)– Begin ARDSnet protocol:

• Low tidal volumes• Increase PEEP rather than FiO2• Consider increasing sedation to promote synchrony

with ventilator

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Accidental Extubation

• Role of the Nurse:

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

– Attach the face mask to the Ambu bag and after ensuring a good seal on the patient’s face; supply the patient with ventilation.

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Pulmonary Disease: Obstructive

Airway obstruction causing increase resistance to airflow: e.g. asthma

• Optimize expiratory time by minimizing minute ventilation• Bag slowly after intubation • Don’t increase ventilator rate for increased CO2

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Pulmonary Disease: Restrictive

Compromised lung volume:– Intrinsic lung disease – External compression of lung

• Recruit alveolia, optimize V/Q matching• Lung protective strategies

– High PEEP– Pressure limiting PIP: 30-35 cmH2O– Low tidal volume: 4-8 ml/kg– FiO2 <60%– Permissive hypercarbia– Permissive hypoxia

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In a patient with head injury,

• Respiratory alkalosis may be required to promote cerebral vasoconstriction, with a resultant decrease in ICP.

• In this case, the tidal volume and respiratory rate are increased

( hyperventilation) to achieve the desired alkalotic pH by manipulating the PaCO2.

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Complications of Mechanical Ventilation:-

I- Airway Complications, II- Mechanical complications,

III- Physiological Complications,

IV- Artificial Airway Complications.

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I- Airway Complications

1- Aspiration

2- Decreased clearance of secretions

3- Nosocomial or ventilator-acquired pneumonia

WHAT IS SUCTIONING?.....

The patient with an artificial airway is not capable of effectively coughing, the mobilization of secretions from the trachea must be facilitated by aspiration. This is called as suctioning.

Indications Coarse breath sounds Noisy breathing Visible secretions in the airway Decreased SpO2 in the pulse oximeter & Deterioration of

arterial blood gas values Clinically increased work of breathing Changes in monitored flow/pressure graphics Increased PIP; decreased Vt during ventilation

NECESSARY EQUIPMENT

Vaccum source with adjustable regulator suction jar

stethoscope Sterile gloves for open suctioning method Clean gloves for closed suctioning method Sterile catheter Clear protective goggles, apron & mask Sterile normal saline Bain’s circuit or ambu bag for

preoxygenate the patient Suction tray with hot water for flushing

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TYPES OF SUCTIONING

OPEN SUCTION CLOSED SUCTION

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OPEN SUCTION SYSTEM: Regularly using system in the intubated

patients.

CLOSED SUCTION SYSTEM: This is used to facilitate continuous

mechanical ventilation and oxygenation during the suctioning.

Closed suctioning is also indicated when PEEP level above 10cmH2O.

Patient Preparation

Explain the procedure to the patient (If patient is concious).

The patient should receive hyper oxygenation by the delivery of 100% oxygen for >30 seconds prior to the suctioning (by increasing the FiO2 by mechanical ventilator).

Position the patient in supine position. Auscultate the breath sounds.

PROCEDUREPerform hand hygiene, wash

hands. It reduces transmission of microorganisms.

Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. For adult a pressure of 100-120 mmHg, 80-100mmhg for children & 60-80mmhg for infants.

Goggles, mask & apron should be worn to prevent splash from secretions

Preoxygenate with 100% O2

Open the end of the suction catheter package & connect it to suction tubing (If you are alone)

Wear sterile gloves with sterile technique

With a help of an assistant open suction catheter package & connect it to suction tubing

Continue…..

Continue…..With a help of an assistant disconnect

the ventilatorKink the suction tube & insert the

catheter in to the ETtube until resistance is felt

Resistance is felt when the catheter impacts the carina or bronchial mucosa, the suction catheter should be withdrawn 1cm out before applying suction

Continue.....Apply continuous suction while rotating

the suction catheter during removalThe duration of each suctioning should

be less the 15sec.Instill 3 to 5ml of sterile normal saline in

to the artificial airway, if requiredAssistant resumes the ventilatorGive four to five manual breaths with

bag or ventilator

Continue….. Continue making suction passes, bagging patient between

passes, until clear of secretions, but no more than four passes

Return patient to ventilator Flush the catheter with hot water in the suction tray Suction nares & oropharynx above the artificial airway Discard used equipments Flush the suction tube with hot water Auscultate chest Wash hands Document including indications for suctioning & any

changes in vitals & patient’s tolerance

Closed suctioning procedure

Wash handsWear clean glovesConnect tubing to closed suction

portPre-oxygenate the patient with

100% O2

Gently insert catheter tip into artificial airway without applying suction, stop if you met resistance or when patient starts coughing and pull back 1cm out

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Closed suction

Continue….. Place the dominant thumb over

the control vent of the suction port, applying continuous or intermittent suction for no more than 10 sec as you withdraw the catheter into the sterile sleeve of the closed suction device

Repeat steps above if needed Clean suction catheter with sterile

saline until clear; being careful not to instill solution into the ETtube

Suction oropharynx above the artificial airway

Wash hands

http://images.search.yahoo.com/search/images/view?back=http%3A%2F%2Fsearch.yahoo.com%2Fsearch%3Fp%3Dphotos%2Bfor%2Bendotracheal%2Bsuctioning%26toggle%3D1%26cop%3Dmss%26ei%3DUTF-8&h=700&w=1004&imgcurl=connection.lww.com%2FProducts%2Fevans-smith%2Fdocuments%2Fc14%2Fjpg%2FF1925-014-019_8.jpg&imgurl=connection.lww.com%2FProducts%2Fevans-smith%2Fdocuments%2Fc14%2Fjpg%2FF1925-014-019_8.jpg&size=114.5kB&name=F1925-014-019_8.jpg&rcurl=http%3A%2F%2Fconnection.lww.com%2FProducts%2Fevans-smith%2FSkill%252014-19.asp&rurl=http%3A%2F%2Fconnection.lww.com%2FProducts%2Fevans-smith%2FSkill%252014-19.asp&p=endotracheal+suctioning&type=jpeg&no=2&tt=16&fr=yfp-t-414

ASSESSMENT OF OUTCOMEImprovement in breath sounds. Decreased peak inspiratory pressure;

Increased tidal volume delivery during ventilation.

Improvement in arterial blood gas values or saturation as reflected by pulse oximetry. (SpO2)

Removal of pulmonary secretions.

CONTRAINDICATIONS

Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure.

Suctioning is contraindicated when there is fresh bleeding.

When indicated, there is no absolute contraindication to endotracheal suctioning because the decision to abstain from suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.

LIMITATIONS OF METHOD

Suctioning is potentially an harmful procedure if carriedout improperly.

Suctioning should be done when clinically necessary (not routinely).

The need for suctioning should be assessed at least every 2hrs or more frequently as need arises.

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• http://www.youtube.com/watch?v=bXXWNCYZ_N0

http://www.youtube.com/watch?v=bXXWNCYZ_N0

http://www.youtube.com/watch?v=bXXWNCYZ_N0

LIMITATIONS OF METHOD

Suctioning is potentially an harmful procedure if carriedout improperly.

Suctioning should be done when clinically necessary (not routinely).

The need for suctioning should be assessed at least every 2hrs or more frequently as need arises.

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II- Mechanical complications1- Hypoventilation with atelectasis with respiratory acidosis or hypoxemia.2- Hyperventilation with hypocapnia and respiratory alkalosis3- Barotrauma a- Closed pneumothorax, b- Tension pneumothorax, c- Pneumomediastinum, d- Subcutaneous emphysema.4- Alarm “turned off”5- Failure of alarms or ventilator6- Inadequate nebulization or humidification7- Overheated inspired air, resulting in hyperthermia

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III- Physiological Complications

1- Fluid overload with humidified air and sodium chloride (NaCl) retention2- Depressed cardiac function and hypotension3- Stress ulcers4- Paralytic ileus5- Gastric distension6- Starvation7- Dyssynchronous breathing pattern

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IV- Artificial Airway ComplicationsA- Complications related to

Endotracheal Tube:-

1- Tube kinked or plugged2- Tracheal stenosis or tracheomalacia3- Mainstem intubation with contralateral (located on

or affecting the opposite side of the• Lung) lung atelectasis5- Cuff failure6- Sinusitis7- Otitis media8- Laryngeal edema

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B- Complications related to Tracheostomy tube:-

1- Acute hemorrhage at the site2- Air embolism3- Aspiration4- Tracheal stenosis5- Failure of the tracheostomy cuff6- Laryngeal nerve damage7- Obstruction of tracheostomy tube8- Pneumothorax9- Subcutaneous and mediastinal emphysema10- Swallowing dysfunction11- Tracheoesophageal fistula12- Infection14- Accidental decannulation with loss of airway

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Nursing care of patients on mechanical ventilation

Assessment:

1- Assess the patient

2- Assess the artificial airway (tracheostomy or endotracheal tube)

3- Assess the ventilator

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Nursing Interventions

1-Maintain airway patency & oxygenation2- Promote comfort3- Maintain fluid & electrolytes balance4- Maintain nutritional state5- Maintain urinary & bowel elimination6- Maintain eye , mouth and cleanliness and

integrity:-7- Maintain mobility/ musculoskeletal

function:-

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Nursing Interventions

8- Maintain safety:-9- Provide psychological support10- Facilitate communication11- Provide psychological support &

information to family 12- Responding to ventilator alarms

/Troublshooting ventilator alarms13- Prevent nosocomial infection14- Documentation

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Responding To Alarms• If an alarm sounds, respond immediately because

the problem could be serious.

• Assess the patient first, while you silence the alarm.

• If you can not quickly identify the problem, take the patient off the ventilator and ventilate him with a resuscitation bag connected to oxygen source until the physician arrives.

• A nurse or respiratory therapist must respond to every ventilator alarm.

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• Alarms must never be ignored or disarmed.

• Ventilator malfunction is a potentially

serious problem. Nursing or respiratory therapists perform ventilator checks every 2 to 4 hours, and recurrent alarms may alert the clinician to the possibility of an equipment-related issue.

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• When device malfunction is suspected, a second person manually ventilates the patient while the nurse or therapist looks for the cause.

• If a problem cannot be promptly corrected by ventilator adjustment, a different machine is procured so the ventilator in question can be taken out of service for analysis and repair by technical staff.

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WEANING

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Weaning readiness Criteria

• Awake and alert

• Hemodynamically stable, adequately resuscitated, and not requiring vasoactive support

• Arterial blood gases (ABGs) normalized or at patient’s baseline

- PaCO2 acceptable - PH of 7.35 – 7.45 - PaO2 > 60 mm Hg , - SaO2 >92% - FIO2 ≤40%

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• Positive end-expiratory pressure (PEEP) ≤5 cm H2O

• F < 25 / minute• Vt 5 ml / kg • VE 5- 10 L/m (f x Vt)• VC > 10- 15 ml / kg

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• Chest x-ray reviewed for correctable factors; treated as indicated,

• Major electrolytes within normal range,• Hematocrit >25%,• Core temperature >36°C and <39°C,• Adequate management of

pain/anxiety/agitation,• Adequate analgesia/ sedation (record scores

on flow sheet),• No residual neuromuscular blockade.

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Methods of Weaning

1- T-piece trial,

2- Continuous Positive Airway Pressure (CPAP) weaning,

3- Synchronized Intermittent Mandatory Ventilation (SIMV) weaning,

4- Pressure Support Ventilation (PSV) weaning.

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1- T-Piece trial

• It consists of removing the patient from the ventilator and having him / her breathe spontaneously on a T-tube connected to oxygen source.

• During T-piece weaning, periods of ventilator support are alternated with spontaneous breathing.

• The goal is to progressively increase the time spent off the ventilator.

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2-Synchronized Intermittent Mandatory Ventilation ( SIMV) Weaning

• SIMV is the most common method of weaning.

• It consists of gradually decreasing the number of breaths delivered by the ventilator to allow the patient to increase number of spontaneous breaths

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3-Continuous Positive Airway Pressure ( CPAP) Weaning

• When placed on CPAP, the patient does all the work of breathing without the aid of a back up rate or tidal volume.

• No mandatory (ventilator-initiated) breaths are delivered in this mode i.e. all ventilation is spontaneously initiated by the patient.

• Weaning by gradual decrease in pressure value

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4- Pressure Support Ventilation (PSV) Weaning

• The patient must initiate all pressure support breaths. • During weaning using the PSV mode the level of pressure

support is gradually decreased based on the patient maintaining an adequate tidal volume (8 to 12 mL/kg) and a respiratory rate of less than 25 breaths/minute.

• PSV weaning is indicated for :-

- Difficult to wean patients - Small spontaneous tidal volume.

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Role of nurse before weaning:-1- Ensure that indications for the implementation of

Mechanical ventilation have improved2- Ensure that all factors that may interfere with successful

weaning are corrected:- - Acid-base abnormalities - Fluid imbalance - Electrolyte abnormalities - Infection

- Fever - Anemia - Hyperglycemia - Sleep deprivation

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Role of nurse before weaning:-

3- Assess readiness for weaning 4- Ensure that the weaning criteria / parameters are

met.5- Explain the process of weaning to the patient and

offer reassurance to the patient.6- Initiate weaning in the morning when the patient is

rested.7- Elevate the head of the bed & Place the patient

upright8- Ensure a patent airway and suction if necessary

before a weaning trial,

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Role of nurse before weaning:-9 - Provide for rest period on ventilator for 15 – 20

minutes after suctioning.10- Ensure patient’s comfort & administer pharmacological agents for comfort, such as bronchodilators or sedatives as indicated. 11- Help the patient through some of the discomfort and apprehension.

13- Evaluate and document the patient’s response to weaning.

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Role of nurse during weaning:-

1- Wean only during the day.2- Remain with the patient during initiation of weaning.3- Instruct the patient to relax and breathe normally.4- Monitor the respiratory rate, vital signs, ABGs, diaphoresis and use of accessory muscles frequently.

If signs of fatigue or respiratory distress develop.

• Discontinue weaning trials.

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Signs of Weaning Intolerance Criteria

• Diaphoresis

• Dyspnea & Labored respiratory pattern

• Increased anxiety ,Restlessness, Decrease in level of consciousness

• Dysrhythmia,Increase or decrease in heart rate of >

20 beats /min. or heart rate > 110b/m,Sustained heart rate >20% higher or lower than baseline

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Signs of Weaning Intolerance CriteriaIncrease or decrease in blood pressure of > 20 mm Hg Systolic blood pressure >180 mm Hg or <90 mm Hg

• Increase in respiratory rate of > 10 above baseline or > 30

Sustained respiratory rate greater than 35 breaths/minute

• Tidal volume ≤5 mL/kg, Sustained minute ventilation <200 mL/kg/minute

• SaO2 < 90%, PaO2 < 60 mmHg, decrease in PH of < 7.35.

Increase in PaCO2

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Role of nurse after weaning

1- Ensure that extubation criteria are met .

2- Decanulate or extubate 2- Documentation

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Noninvasive Bilateral Positive Airway Pressure Ventilation (BiPAP)

• BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or nasal prongs, or a full-face mask.

• The system allows the clinician to select two levels of positive-pressure support:

• An inspiratory pressure support level (referred to as IPAP)

• An expiratory pressure called EPAP (PEEP/CPAP level).

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NON INVASIVE VENTILATION

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Absolute contraindications

• Coma• Cardiac arrest• Respiratory arrest• Any condition requiring immediate intubation

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Suitable clinical conditions

• Chronic obstructive pulmonary disease• Cardiogenic pulmonary edema• After discontinuation of

mechanical ventilation (COPD)• OSP

http://emedicine.medscape.com/article/304068-overview

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Patient interfaces

• full face masks,• nasal pillows, • Nasal masks • and orofacial masks

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Ventilators

• Usual ventilators for invasive ventilation• Special noninvasive ventilators• Modes of ventilation• CPAP• BiPAP

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Top 10 care essentials for ventilator patients

• Review communications.• Check ventilator settings and modes.• Suction appropriately.• Assess pain and sedation needs.• Prevent infection.

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Top 10 care essentials for ventilator patients

• Prevent hemodynamic instability.• Manage the airway.• Meet the patient’s nutritional needs.• Wean the patient from the ventilator

appropriately.• Educate the patient and family.

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THANK

YOU

Mechanical ventilation ppt

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