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Transcript of Ventilator Basics Application for Physical and …c.ymcdn.com/sites/ · Introduction & Application...
Mechanical VentilationIntroduction & Application for Physical Therapists
Lindsey Montana Fan, PT, DPT, CCSNYPTA Greater District of New York
September 10th, 2014
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Objectives
Understand the premise & main indications for mechanical ventilation
Obtain/interpret information on settings & patient performance from ventilator screen
Become familiar with basic ventilator terminology & modes
Identify PT treatment indications for mechanically ventilated & weaning patients
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Why not wait until the patient is extubated?
Muscle Strength decreases 1.3-3% for each day the healthy individual spends on bedrest (Topp, et al. 2002)
Effects are even more profound in older individuals & those with critical illness (Yende, et al.
2006)
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Ventilation
Ventilation is the process by which gases are moved in & out of the lungs
Spontaneous Ventilation is a result of negative intrathoracic pressure being created by the inspiratory muscles Muscles contract & pull on pleura Pressure in the intrapleural space decreases Negative pressure gradient pulls air from the atmosphere into the
lungs
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Mechanical Ventilation
Mechanical Ventilation is the use of artificial means to support or replace spontaneous ventilation
Mechanical Ventilation must satisfy a patient’s respiratory needs without Damaging the lungs Impairing circulation Causing patient discomfort
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Indications Mechanical Ventilation
Hypoxemic Respiratory Failure Inadequate Gas Exchange Decrease in PaO2 Inability to maintain % oxygen
saturation
Hypoventilation V/Q mis-match Diffusion Impairment
Hypercapnic Respiratory Failure Increase in PaCO2 Inability to ventilate
Respiratory muscle fatigue Neuromuscular disorders CNS depression Musculoskeletal disorders
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Indications Mechanical Ventilation
Airway Protection Preventative Measure
Cardiac Arrest Life-saving measure
Management of ICP Creation of alkalosis --> vasoconstriction --> decreased cerebral blood flow/reduction of ICP
Airway Obstruction Maintenance of patent airway
Surgery or Trauma General Anesthesia
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Delivery
Endotracheal TubeNasal Endotracheal TubeTracheostomy
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Key Units of Measurement
Volume mL
Pressure cmH2O
Flow L/min
Rate Breaths/min
FiO2 %
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Types of Mechanical Ventilation
Pressure Ventilation Negative pressure ventilation
• Iron Lung• Chest Cuirass
Positive pressure ventilation• The application of positive pressure to the lungs to
improve gas exchange • The opposite of natural “spontaneous breathing”
Volume Ventilation The application of supplemental volume to the lungs to improve gas
exchange
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Screen Organization
Patient Performance Data
Clinician Entered Settings
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Modes: Assist-Control
Full Ventilatory SupportMandatory breaths delivered at set parameters
RateInspiratory Pressure or VolumeFiO2PEEP
Ventilator will also support any patient-triggered breaths at these set parameters
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Assist-Control Settings ViewMode
Pressure Control (PC)
Rate (f)
Inspiratory Pressure (PI)
FiO2 (O2 %)
PEEP
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Assist-Control Performance Data View
Type of Breath Delivered (A or C)
Respiratory Rate (fTOT)
Tidal Volume (VTE)
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Modes: Spontaneous
All breaths are initiated & terminated by the patient.
Ventilator assists the patient’s inspiratory efforts toOver-come airway resistance Augment tidal volumesDecrease work of breathing
Mode SettingsPressure SupportFiO2PEEP
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Spontaneous Settings View
Mode Spontaneous (SPONT)
Pressure Support (PS)
FiO2 (O2 %)
PEEP
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Spontaneous Performance Data View
Type of Breath Delivered (S)
Respiratory Rate (fTOT)
Tidal Volume (VTE)
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PEEP
Positive End Expiratory Pressure
Elevates baseline pressure at which inspiration is delivered
Increases alveolar recruitment & surface area available for gas exchange
Prevents alveolar collapse at end-expiration
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Alarms
Red AlarmsCircuit DisconnectApnea
Yellow AlarmsLow Tidal VolumeHigh Respiratory RateHigh Pressure
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Adverse Side-Effects Prolonged Exposure to Mechanical Ventilation
Impaired CirculationDecreased Cardiac Out-putVentilator-Induced Lung InjuryRespiratory Muscle AtrophyBarotraumaVentilator-Associated Pneumonia
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Application for Physical Therapists
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PT Considerations Call Respiratory Therapy
For status update, notification, & assistance Understand hospital policy
Schedule Assistant Time
Monitor Patient Performance Top of ventilator screen Vital signs
Suctioning Competency Ballard/Closed In-Line Suction
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ET Tube Placement
Placement indicator at level of teeth or lip
Confirm placement with RT or RN before & after mobilization
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Documentation
Assist-Control
ModeInspiratory Pressure or
VolumeSet RateFiO2PEEP
Spontaneous
ModePressure SupportFiO2PEEP
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Ventilator Weaning
Ventilatory discontinuance. The process of reducing ventilator support
Goal: Restoration of pt.’s ability to independently & adequately ventilate without the mechanical ventilator
Changing the modeChanging the settingsTrach collar trial/T-piece trial
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Weaning Considerations
VO2 increases with all forms of exercise Increase in cardiac out-put Increase O2 extraction across capillary beds
Spontaneous breathing trials Reduction of Ventilator support Pressure Support/Trach Collar
Can increase cardiovascular work-load
Tailor treatments accordingly Monitor patient tolerance Provide adequate rest periods
MORE vent support is BETTER For PT/OT during preliminary weaning trials Exercise clinical judgement
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Exercise Intolerance
In the setting of increasing workload...
Increasing respiratory rateDecreasing tidal volumesIncreasing accessory muscle use
Looks for the signs, know when to take a break!
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Safety & Feasibility---The Evidence Mobilization with Patients Receiving Mechanical Ventilation
One study conducted 1,449 activity events in 103 mechanically ventilated patients. Adverse activity-related events occurred in <1% No patients were extubated during activity (Bailey, et al. 2007)
Another study conducted PT & OT in 49 mechanically ventilated patients on a median of 1.5 days s/p intubation Therapy was provided on 90% of MICU days 89% of patients encountered had at least 1 potential barrier to
mobilization in addition to mechanical ventilation Therapy was interrupted prematurely in only 4% of all sessions (Pohlman, et al.
2010)
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Evidence Continued
Prospective, observational study 179 mobilization therapies with 63 critically ill patients
Patient level of mobilization achieved by Physical Therapists was significantly higher than that achieved by Registered Nurses (Garzon-Serrano, et. al 2011)
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Early Mobilization
A strategy for whole-body rehabilitation---consisting of interruption of sedation & physical & occupational therapy in the earliest days of critical illness
Safe & effectiveBetter functional outcomes at hospital dischargeShorter duration of deliriumMore ventilator-free days compared with standard of
careDecreased length of hospital stay (Schweickert, et al. 2009)
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References Bailey P, Thomsen G, Spuhler V, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007(35): 139-145.
Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. Missouri: Mosby Elsevier; 2006.
Garzon-Serrano J, Ryan C, Waak K, et al. Early mobilization in critically ill patients: patients’ mobilization level depends on healthcare provider’s profession. PM&R. 2011(3): 307-313.
Hillegass E, Fick A, Pawlik A, et al. Supplemental oxygen utilization during physical therapy interventions. Cardiopulmonary Physical Therapy Journal. 2014(25): 38-49.
Korupolu R, Gifford J, Needham D. Early mobilization of critically ill patients: reducing neuromuscular complications after intensive care. Contemporary Critical Care. 2009(6): 1-12.
Kress J. Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009(37):s442-s447.
Martin K. Mechanical ventilation: an overview. RC Educational Consulting Services, Inc. Apr 2000.
Patman S, Dennis D, Hill K. Exploring the capacity to ambulate after a period of prolonged mechanical ventilation. Journal of Critical Care Med. 2012(27): 542-548.
Pinsky M. Breathing as exercise: the cardiovascular response to weaning from mechanical ventilation. Intensive Care Med. 2000(26): 1164-1166.
Pohlman M, Schweickert W, Pohlman A, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010(38): 2089-2094.
Schweickert W, Pohlman M, Pohlman A, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009(373): 1874-82.
Topp R, Ditmyer M, King K, et al. The effect of bedrest and potential of prehabilitation on patients in the intensive care unit. AACN Clin Issues. 2002(13): 263-276.
Wilkins R, Stoller J, Scanlan C. Egan’s Fundamentals of Respiratory Care. Missouri: Mosby; 2003.
Yende S, Waterer G, Tolley E, et al. Inflammatory markers are associated with ventilatory limitation and muscle dysfunction in obstructive lung disease in well functioning elderly subjects. Thorax. 2006(61): 10-16.
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