8. ventilator nursing care

ventilator care

1. CARE OF THE PATIENT
ON VENTILATOR
1Prof. Dr. RS Mehta, BPKIHS

2. VENTILATOR
Amechanicalventilatorisa
positiveornegativepressure
breathingdevicethatcan
maintainventilationandoxygen
deliveryforaprolongedperiod.
Mechanicalventilationhasbeen
usedfordecadestosupportthe
respiratoryfunctionsofpatients
withvariousdegreesof
respiratorydistressorfailure.
2Prof. Dr. RS Mehta, BPKIHS

3. 3Prof. Dr. RS Mehta, BPKIHS

4. 4Prof. Dr. RS Mehta, BPKIHS

5. PURPOSES
Tomaintaingasexchangeincaseofacute
andchronicrespiratoryfailure.
TomaintainventilatorysupportafterCPR.
Toreducepulmonaryvascularresistance.
ToexcreteincreasedCO2production.
Togivegeneralanesthesiawithmuscle
relaxants.
5Prof. Dr. RS Mehta, BPKIHS

6. Indications for Mechanical Ventilation
UpperairwayobstructionandLower
airwayobstructionasaresultof
blockage.
Neuromusculardisordersasin
Myastheniagravis,Poliomyelitis,
Gullian-Barresyndrome,Snakebiteand
inadequatereversalofanesthesia.
6Prof. Dr. RS Mehta, BPKIHS

7. ContD…
Lung diseases which prevent proper
exchange of O
2and CO
2as in Chest Injuries
Pneumothorax, lung Infections, COPD,
Acute Respiratory Distress Syndrome
(ARDS).
Post-operative cardiac surgery, any other
surgery, shock & trauma.
Respiratory arrest.
7Prof. Dr. RS Mehta, BPKIHS

8. Criteria for institution of ventilator support:
Normal
range
(adult)
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 H
2O) 8Prof. Dr. RS Mehta, BPKIHS

9. Criteria for institution of ventilatorysupport:
Normal
range
Ventilation
indicated
Parameters
7.35-7.45
75-100
35-45
< 7.25
< 60
> 50
B-Arterial blood
Gases
•PH
•PaO
2(mmHg)
•PaCO
2(mmHg)
9Prof. Dr. RS Mehta, BPKIHS

10. Classification of Ventilators
Ventilator
Positive pressure Negative pressure
10Prof. Dr. RS Mehta, BPKIHS

11. NEGATIVE PRESSURE VENTILATOR
Elongatedtank,whichencasesthepatientuptothe
neck.Theneckissealedwitharubbergasket,the
patient'sfaceareexposedtotheroomair.
Theseexertnegativepressureontheexternalchest
decreasingtheintra-thoracicpressureduring
inspiration,allowsairtoflowintothelungs,filling
itsvolume.
Thecessationofthenegativepressurecausesthe
chestwalltofallandexhalationtooccur.
11Prof. Dr. RS Mehta, BPKIHS

12. 12Prof. Dr. RS Mehta, BPKIHS

13. Contd…
Thesearesimpletouseanddonotrequire
intubationsoftheairway;consequently,theyare
especiallyadaptableforhomeuse.
Itisusedmainlyinchronicrespiratoryfailure
associatedwithneuromuscularconditionssuchas
poliomyelitis,musculardystrophyandmyasthenia
gravis.
Theuseofnegative-pressureventilatorsisrestricted
inclinicalpractice,however,becausetheylimit
positioningandmovementandtheylackadaptability
tolargeorsmallbodytorsos(chests).
13Prof. Dr. RS Mehta, BPKIHS

14. 14Prof. Dr. RS Mehta, BPKIHS

15. 15Prof. Dr. RS Mehta, BPKIHS

16. POSITIVE PRESSURE VENTILATION
Positivepressureventilatorsinflate
thelungsbyexertingpositive
pressureontheairwayforcingthe
alveolitoexpandduringinspiration.
Expirationoccurspassively.
16Prof. Dr. RS Mehta, BPKIHS

17. ContD…
Positive-pressureventilatorsrequirean
artificialairway(Endotrachealortracheostomy
tube)andusepositivepressuretoforcegas
intoapatient'slungs.
Inspirationcanbetriggeredeitherbythe
patientorthemachine.
17Prof. Dr. RS Mehta, BPKIHS

18. Origins of mechanical ventilation
•Negative-pressure ventilators
(“iron lungs”)
•Non-invasive ventilation first
used in Boston Children’s
Hospital in 1928
•Used extensively during polio
outbreaks in 1940s –1950s
•Positive-pressure ventilators
•Invasive ventilation first used at
Massachusetts General Hospital
in 1955
•Now the modern standard of
mechanical ventilation
The era of intensive care medicine began with positive-pressure ventilation
The iron lung created negative pressure in abdomen
as well as the chest, decreasing cardiac output.
Iron lung polio ward at Rancho Los Amigos Hospital
in 1953.
18Prof. Dr. RS Mehta, BPKIHS

19. Mechanical Ventilators Classification
19Prof. Dr. RS Mehta, BPKIHS

20. 1.Control:
Howtheventilatorknowshowmuchflowtodeliver?
VolumeControlled
(volumelimited,volumetargeted)andPressure
Variable
PressureControlled
(pressurelimited,pressuretargeted)andVolume
Variable
DualControlled
(volumetargeted,pressurelimited)
20Prof. Dr. RS Mehta, BPKIHS

21. 2.Cycling
how the ventilator switches from inspiration to
expiration
Time, flow, volume & pressure cycling
mechanism.
Timecycled:
-is terminated to the expiratory phase once a
predetermined inspiratory time elapses
-it is used for neonates and in the operating
room
21Prof. Dr. RS Mehta, BPKIHS

22. Flowcycled:
-Whentheflowreachestoapredeterminedlevel,the
ventilatorcyclesfrominspirationintoexpiration
irrespectiveofinspiratorytime&VT.
-Havepressureandflowsensors.
Pressure-cycled:
-Terminateintotheexpiratoryphasewhenairway
pressurereachestoapredeterminedlevel,irrespective
ofVT,inspiratorytimeorinspiratoryflowrate.
-Pressure-cycledventilatorsaregenerallymost
usefulforshort-termuseonly(transport).
22Prof. Dr. RS Mehta, BPKIHS

23. Volume cycled:
Terminate in inspiration when a preselected
volume is delivered.
Many adult ventilators are volume cycled but
also have secondary limits on inspiratory
pressure to guard against pulmonary
barotrauma.
If inspiratory pressure exceeds the pressure
limit, the machine cycles into expiration even
if the selected volume has not been delivered.
23Prof. Dr. RS Mehta, BPKIHS

24. 3.Triggering
(Whatcausestheventilatortocycletoinspiration?)
Time:Theventilatorcyclesatasetfrequencyas
determinedbythecontrolledrate.
Pressure:Theventilatorsensesthept'sinspiratoryeffort
bywayofa↓inthebaselinepressure.
Flow:Modernventilatorsdeliveraconstantflowaround
thecircuitthroughouttherespiratorycycle.A
deflectioninthisflowbypatientinspiration,is
monitoredbytheventilatoranditdeliversabreath,
requireslessworkbythepatientthanpressure
triggering.
24Prof. Dr. RS Mehta, BPKIHS

25. VENTILATION STRATEGIES
1.Assistedspontaneousbreathing:
a)ContinuousPositiveAirwayPressure(CPAP)
b)PositiveEndExpiratoryPressure(PEEP)
2.Supported spontaneous breathing:
(Pressure or volume support in spontaneous
breathing)
a)PressureSupportVentilation
b)VolumeSupportVentilation
25Prof. Dr. RS Mehta, BPKIHS

26. ContD…
3.Mixedrespiratorysupport:
a)IntermittentMandatoryVentilation(IMV)
b)Synchronized Intermittent Mandatory
Ventilation (SIMV).
4.Controlledmechanicalventilation:
a)PressureControlledVentilation
b)VolumeControlledVentilation
c)ControlledVentilation
d)HighFrequencyVentilation
26Prof. Dr. RS Mehta, BPKIHS

27. important ventilation modes
ControlledMechanicalVentilation(CMV)
-PressureControlledVentilation(PCV)
-VolumeControlledVentilation(VCV)
IntermittentPositivePressureVentilation(IPPV)
PressureSupportVentilation(PSV)
SynchronizedIntermittentMandatoryVentilation
(SIMV)
Bi-levelPositiveAirwayPressure(BIPAP)
Continuouspositiveairwaypressure(CPAP)
InverseRatioVentilation(IRV)
27Prof. Dr. RS Mehta, BPKIHS

28. Pressure-cycled modes
•Pressure Support Ventilation (PSV)
•Pressure Control Ventilation (PCV)
•CPAP
•BiPAP
Volume-cycled modes
•Assist/Control Ventilation
•Intermittent Mandatory Ventilation (IMV)
•Synchronous Intermittent Mandatory Ventilation
(SIMV)
28Prof. Dr. RS Mehta, BPKIHS

29. CPAP
TheeffectofCPAPiscomparedtoinflatinga
balloonbutnotlettingitcompletelydeflate
beforeinflatingitagain.Thesecondinflationis
easiertoperformbecauseresistanceisdecreased.
Acontinuouslevelofelevatedpressureisprovided
throughthepatientcircuittomaintainadequate
oxygenation,decreasetheworkofbreathing.
CPAPmaybeusedinvasivelythroughan
endotrachealtubeortracheostomyornon-
invasivelywithafacemaskornasalprongs.
29Prof. Dr. RS Mehta, BPKIHS

30. PEEP
PEEPispositivepressurethatisapplied
bytheventilatorattheendofexpiration.
Thismodedoesnotdeliverbreathsbutis
usedasanadjuncttoCVandSIMVto
improveoxygenationbyopening
collapsedalveoliattheendofexpiration.
30Prof. Dr. RS Mehta, BPKIHS

31. CONTd…
Complicationsfromtheincreasedpressurecan
includedecreasedcardiacoutput,lungrupture,
andincreasedintracranialpressure.
Itisusedtoincreasethesurfaceareatoprevent
collapseofalveoliandtopreventatelectasis.
PEEPisfunctionallythesameasCPAP,butrefersto
theuseofanelevatedpressureduringtheexpiratory
phaseoftheventilatorycycle.
31Prof. Dr. RS Mehta, BPKIHS

32. INTERMITTENTMANDATORY VENTILATION (IMV)
A mode of mechanical ventilation in
which the patient is allowed to breathe
independently except during certain
prescribed intervals, when a ventilator
delivers a breath either under positive
pressure or in a measured volume.
32Prof. Dr. RS Mehta, BPKIHS

33. Synchronized Intermittent Mandatory Ventilation (SIMV)
Inthismodetheventilatorprovidesapre-setmechanical
breath(pressureorvolumelimited)everyspecified
numberofseconds(determinedbydividingthe
respiratoryrateinto60-thusarespiratoryrateof12
resultsina5secondcycletime).
Withinthatcycletimetheventilatorwaitsforthe
patienttoinitiateabreathusingeitherapressureor
flowsensor.Whentheventilatorsensesthefirst
patientbreathingattemptwithinthecycle,itdelivers
thepresetventilatorbreath.
Ifthepatientfailstoinitiateabreath,theventilator
deliversamechanicalbreathattheendofthebreath
cycle.
33Prof. Dr. RS Mehta, BPKIHS

34. CONTD…
SIMVisusedasaprimarymodeofventilationas
wellasaweaningmode.(Duringweaning,the
presetrateisgraduallyreduced,allowingthepatient
toslowlyregainbreathingontheirown.)
Thedisadvantageofthismodeisthatitmay
increasetheeffortofbreathingandcauserespiratory
musclefatigue.
Whenpatientisbreathingindependentlyand
adequately,ventilatordoesnotsupport.
Note:Theventilatorinitiateseachbreathin
synchronywiththepatient'sbreaths.
34Prof. Dr. RS Mehta, BPKIHS

35. CONTROLLED VENTILATION: IPPV
Theventilatorinitiatesandcontrolsboththe
volumedeliveredandthefrequencyofbreaths.
•Thismodeisusedforpatientswhoareunableto
initiateabreath.
•Itisindicatedinpatientswithapnea,drug
overdose,spinalcordinjuries,CNSdysfunction,
flailchest,neuromusculardisease,andparalysis
fromdrugs.
•Ifitisusedwithspontaneouslybreathingpatients,
theymustbesedatedand/orpharmacologically
paralyzedsotheydon'tbreatheoutofsynchrony
withtheventilator.
35Prof. Dr. RS Mehta, BPKIHS

36. ASSIST CONTROL VENTILATION
This mode is used for pts. who can initiate a breath but
who have weakened respiratory muscles.
In this mode, the ventilator provides a mechanical breath
with either a pre-set tidal volume or peak pressure every
time the pt. initiates a breath.
If the pt. fail to initiate inspiration, the ventilator
automatically goes into the back up mode and delivers
the pre set rate and tidal volume until it senses an
inspiratory effort.
It is used in disease conditions like Myasthenia gravis,
GB syndrome, post cardiac/respiratory arrest, pulmonary
edema, ARDS, etc.
36Prof. Dr. RS Mehta, BPKIHS

37. INVERSE RATIO VENTILATION (IRV)
Thenormalinspiratory:expiratoryratio
is1:2,butthisisreversedduringIRVto
2:1orgreater(themaximumis4:1).
Thismethodisusedforpatientswhoare
stillhypoxic,evenwiththeuseofPEEP.
37Prof. Dr. RS Mehta, BPKIHS

38. CONTD…
Longerinspiratorytimeincreasestheamountof
airinthelungsattheendofexpiration(the
functionalresidualcapacity)andimproves
oxygenationbyre-expandingcollapsedalveoli.
Theshorterexpiratorytimepreventsthealveoli
fromcollapsingagain.
Thismethodrequiressedationandtherapeutic
paralysisbecauseitisveryuncomfortablefor
thepatient.
38Prof. Dr. RS Mehta, BPKIHS

39. Time Cycled Ventilators
Time-cycledventilatorsterminateor
controlinspirationafterapre-settime.
Theseventilatorsareusedinnewborn&
infants.
39Prof. Dr. RS Mehta, BPKIHS

40. There are several ventilation modes, the most important are:Summary
Controlled Mechanical Ventilation (CMV)
-Pressure Controlled Ventilation (PCV)
-Volume Controlled Ventilation (VCV)
Intermittent Positive Pressure Ventilation
(IPPV)
Pressure Support Ventilation (PSV)
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Bi-level Positive Airway Pressure (BIPAP)
Continuous positive airway pressure (CPAP)
Inverse Ratio Ventilation (IRV)
40
Prof. Dr. RS Mehta, BPKIHS

41. Summary…
Pressure-cycled modes
•Pressure Support Ventilation (PSV)
•Pressure Control Ventilation (PCV)
•CPAP
•BiPAP
Volume-cycled modes
•Assist/Control
•Intermittent Mandatory Ventilation (IMV)
•Synchronous Intermittent Mandatory
Ventilation (SIMV)
41
Prof. Dr. RS Mehta, BPKIHS

42. Initiating Mechanical Ventilation
Initial ventilator settings:
FiO
2 1.0 initially but then reduce
PEEP 5 -7 cmH
2O
Tidal volume 7-10 ml/kg
Inspiratory pressure 20 cmH
2O (15cmH
2O above PEEP)
Frequency 10 -15 breaths per minute
Pressure support (ASB) 20 cmH
2O (15cmH
2O above PEEP)
I:E Ratio 1:2
Flow trigger 2 l/min
Pressure trigger -1 to -3 cmH
2O
Inspiratory flow 60 L/min
**These settings should be titrated against the pt.'s clinical
state and level of comfort.
42Prof. Dr. RS Mehta, BPKIHS

43. 43Prof. Dr. RS Mehta, BPKIHS

44. Indications for intubation
•Criteria
•Clinical deterioration
•Tachypnea: RR >35
•Hypoxia: pO2<60mm Hg
•Hypercarbia: pCO2 > 55mm Hg
•Minute ventilation<10 L/min
•Tidal volume <5-10 ml/kg
•Negative inspiratoryforce <
25cm H2O (how strong the pt
can suck in)
•Initial vent settings
•FiO
2= 50%
•PEEP = 5cm H
2O
•RR = 12 –15 breaths/min
•V
T= 10 –12 ml/kg
•COPD = 10 ml/kg (prevent over-
inflation)
•ARDS = 8 ml/kg (prevent volu-trauma)
•Permissive hyper-capnea
•Pressure Support = 10cm H
2O
How the values trend should significantly impact clinical decisions
44Prof. Dr. RS Mehta, BPKIHS

45. Indications for extubation
•Clinical parameters
•Resolution/Stabilization of
disease process
•Hemodynamicallystable
•Intact cough/gag reflex
•Spontaneous respirations
•Acceptable vent settings
•FiO
2< 50%, PEEP < 8, P
aO
2
> 75, pH > 7.25
•General approaches
•SIMV Weaning
•Pressure Support Ventilation
(PSV) Weaning
•Spontaneous breathing trials
and use of T-piece
•Demonstrated to be superior
No weaning parameter completely accurate when used alone
Numerical
Parameters
Normal
Range
Weaning
Threshold
P/F > 400 > 200
Tidal volume 5 -7 ml/kg 5 ml/kg
Respiratory rate 14 -18 breaths/min< 40 breaths/min
Vital capacity 65 -75 ml/kg 10 ml/kg
Minute volume 5 -7 L/min < 10 L/min
Greater Predictive
Value
Normal
Range
Weaning
Threshold
NIF (Negative
InspiratoryForce)
> -90 cm H2O > -25 cm H2O
RSBI (Rapid
Shallow Breathing
Index) (RR/TV)
< 50 < 100
Marino P,The ICU Book (2/e). 1998.
45Prof. Dr. RS Mehta, BPKIHS

46. Spontaneous Breathing Trials
•Settings
•PEEP = 5, PS = 0 –5, FiO
2< 40%
•Breathe independently for 30 –
120 min
•ABG obtained at end of SBT
•Failed SBT Criteria
•RR > 35 for >5 min
•S
aO
2<90% for >30 sec
•HR > 140
•Systolic BP > 180 or < 90mm Hg
•Sustained increased work of
breathing
•Cardiac dysrhythmia
•pH < 7.32
SBTs do not guarantee that airway is stable or pt can self-clear secretions
Causes of Failed
SBTs
Treatments
Anxiety/Agitation Benzodiazepines or haldol
Infection Diagnosis and tx
Electrolyte abnormalities
(K
+
, PO
4-
)
Correction
Pulmonary edema, cardiac
ischemia
Diuretics and nitrates
Deconditioning,
malnutrition
Aggressive nutrition
Neuromuscular disease Bronchopulmonary hygiene,
early consideration of trach
Increased intra-abdominal
pressure
Semirecumbentpositioning,
NGT
Hypothyroidism Thyroid replacement
Excessive auto-PEEP
(COPD, asthma)
Bronchodilator therapy
Senaet al, ACS Surgery: Principles and
Practice (2005).
46
Prof. Dr. RS Mehta, BPKIHS

47. Guidelines Suggesting the Need for Mechanical Ventilation
Parametersthathelpustoguidetotakethedecision
whethermechanicalventilationisneededornot?
1.Cl.Indices:
Apneawithrespiratoryarrest
RR>35breathsperminute
Paralysisofbreathingmuscle-GBS,MG
headtrauma,coma
-anabsentgagorcoughreflex.
-Effectofanestheticandmusclerelaxant
-Others:shock,CCF,sepsis
47
Prof. Dr. RS Mehta, BPKIHS

48. 2. Mechanical indices
Vital capacity <15 mL/kg
Tidal volume <5 mL/ kg
Maximum inspiratoryforce < –25 cm H
2O
3. Respiratory gas tensions
Direct indices
PaO
2(<60 mm Hg)
PaCO
2(>50 mm Hg with pH <7.25)
Derived indices
PaO
2/FIO
2ratio < 300 mm Hg
48
Prof. Dr. RS Mehta, BPKIHS

49. S.NComponents Values
1.Respiratory rate>35-40/min
2.Tidal capacity < 10-15 ml/kg
3.PaO2 <60-70 mmHg under
O2 therapy
4.PaCO2 >50-55mmHg
5.Inspiratorypressure>20-25 cm H2O
49Prof. Dr. RS Mehta, BPKIHS

50. VENTILATOR ALARMS
ALARM DEFINITION POTENTIALCAUSE
1. High
pressure
•Pressure required to ventilate
exceeds preset pressure
Pneumothorax, excessive
secretions, decreased lung
compliance.
2.Low pressure•Resistanceto inspiratory flow is
less than preset pressure.
Disconnected from ventilator,
breakin circuit.
3.Low exhaled
volume
•Exhaled tidal volume drops
belowpreset amount.
Leak in system, increased
airway resistance, decreased
lung compliance
4.Rate /apnea•Respiratory rate drops below
preset level. Apnea period
exceeds set time
Clientfatigue, decreased R.R
due to medication.
5.FIO2 •Indicates FIO2 driftfrom preset
range.
Changein level of
consciousness, disconnected
from O2 source, break in
circuit.
50Prof. Dr. RS Mehta, BPKIHS

51. COMPLICATIONS OF MECHANICAL
VENTILATION
I.Complication associated with patient’s
response to mechanical ventilation .
II.Complication associated to ventilator
malfunction.
III.Complications related to endotracheal
intubation.
51Prof. Dr. RS Mehta, BPKIHS

52. Complication associated with patient’s
response to mechanical ventilation
1.Decreased cardiac output.
2.Decreased renal perfusion.
3.Positive water balance.
4.Barotraumas.
5.Nosocomial pneumonia.
52Prof. Dr. RS Mehta, BPKIHS

53. Complicationassociatedtoventilator
malfunction
1. Alarms turned off or non-functional
–may lead to apnea and respiratory
arrest.
2. Low exhaled volume.
53Prof. Dr. RS Mehta, BPKIHS

54. Complications related to
endotrachealintubation
1.Sinusitis and nasal injury
2.Tracheoesophagealfistula
3.Laryngeal or tracheal stenosis
4.Cricoidabscess
54Prof. Dr. RS Mehta, BPKIHS

55. NURSINGCARE OF PATIENTS ON VENTILATOR
PHYSIOLOGICAL NEEDS:
comfort
activity
nutrition
elimination of wastes
Patients are often not able to fulfill these needs by
themselves, nursing function is then for example
seeing to comfort, determining intake and output
together with blood chemistry to assess adequacy of
intravenous nutrition, and so on.
55Prof. Dr. RS Mehta, BPKIHS

56. CONTD…
SAFETYNEEDS:
Threatofinjurybypersonormachines
Medicationmustbechecked.Machinesmustbeinbest
workingcondition.
NEEDTOBELONG:
Security,meansofcommunication
Staffmustcommunicatewiththepatientandpatient
mustbeallowedtorespond.Patientsneedconstant
reassurance.
56Prof. Dr. RS Mehta, BPKIHS

57. CONTD…
NEEDFORRECOGNITION:
Esteem,dignity,respect
Patientsmustbetreatedwithrespectandaddressed
correctly.
NEEDTOCREATE:
Expressionofself,needtocontribute
Patientsmustbeinvolvedinthechoiceand
implementationoftheirtreatment.
57Prof. Dr. RS Mehta, BPKIHS

58. CONTD..
NEED TO KNOW AND UNDERSTAND:
Need for knowledge and comprehension
An explanation of diagnosis and treatment on the
patient’s level.
SELF ACTUALIZATION:
Order, truth, privacy
Patients should have as much privacy as possible —
pull screens or close doors. The patient has the right to
be told the truth.
58Prof. Dr. RS Mehta, BPKIHS

59. Nursing Diagnoses
Ineffective breathing pattern
Potential for pulmonary infection
Impaired water and fluid regulation
Oral hygiene
Potential altered nutritional status: less than body
requirement related to NPO status
Potential for complications related to immobility
59Prof. Dr. RS Mehta, BPKIHS

60. Nursing Diagnoses…
Knowledge deficit related to intubation and
mechanical ventilation
Elimination care
Promoting coping ability
Preventing trauma and infections
Promoting rest and sleep
Safety and security needs.
60Prof. Dr. RS Mehta, BPKIHS

61. 61Prof. Dr. RS Mehta, BPKIHS

62. WEANING:
Weaningistheprocessofwithdrawing
mechanicalventilatorsupportandtransferring
theworkofbreathingfromtheventilatortothe
patient.
Itisdoneonlywhenpatientisfreefromthe
causetobekeptonmechanicalventilation.
Weaningsuccessisdefinedaseffective
spontaneousbreathingwithoutanymechanical
ventilationfor24hoursormore.
62Prof. Dr. RS Mehta, BPKIHS

63. Conditions that may hinder successful weaning
Patient/patho-physiologic : fever, infection,
renal failure, sepsis, sleep deprivation.
Cardiac/circulatory: arrhythmias, abnormal
blood pressure, abnormal cardiac output,
fluid imbalance.
Dietary/acid-base/electrolytes: acid-base
imbalance, electrolytes disturbance, anemia.
63Prof. Dr. RS Mehta, BPKIHS

64. Criteria for weaning
Tidal volume be above a given threshold
(greater than 5 ml/kg),
Respiratory frequency be below a given
count (less than 30 breaths/min),
Oxygen partial pressurebe above a given
threshold (PaO2 greater than 60mm Hg) and
FIO2<40%
Vital capacity 10 to 15 ml/kg.
64Prof. Dr. RS Mehta, BPKIHS

65. Since weaning is the graded removal of a
therapeutic modality, the sudden withdrawal
will not be tolerated.
So, weaning from the following 5 modalities
should be independently assessed.
1.Supplemental oxygen
2.PEEP
3.Mechanical ventilation
4.Artificial airway
5.Ionotrops
65Prof. Dr. RS Mehta, BPKIHS

66. 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.
66Prof. Dr. RS Mehta, BPKIHS

67. Signs of Weaning Intolerance Criteria
Diaphoresis
Dyspnoea& 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 > 110 b/m,
Sustained heart rate >20% higher or lower than
baseline
67Prof. Dr. RS Mehta, BPKIHS

68. Criteria…
Increase 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
SpO2 < 90%, PaO2 < 60 mmHg, decrease in PH of <
7.35.
Increase in PaCO
2.
68Prof. Dr. RS Mehta, BPKIHS

69. NURSING CARE OF THE PATIENT BEING WEANED
Assesstheclientfortheweaningcriteria.
Monitortheactivitylevel,assessdietaryintakeand
monitorresultsofthelabtests.
Assessclient’s&family’slevelofunderstandingof
weaning.
Explainthatpatientmayfeelshortnessofbreath
initially&provideencouragementasneeded.
Monitorvitalsigns,pulseoximetry,ECGchanges,
ABGanalysis&respiratorypatterncontinuouslyfor
thefirst20-30min&thenevery5minuntilweaning
iscomplete.
69Prof. Dr. RS Mehta, BPKIHS

70. Nursing Care…
Implement the weaning method prescribed: ASB,
IMV, SIMV, CPAP, T-piece, etc….
Maintain a patent airway, suction the airway as
needed.
Monitor the ABG level & Pulmonary Function Test
as per requirement.
Terminate the weaning if adverse reactions occur.
Assess psychological dependence if the physiologic
parameters indicate weaning is feasible or patient
still resists.
70Prof. Dr. RS Mehta, BPKIHS

71. Elimination Care:
Catheter care
Proper cleaning, use of bed pan if
possible.
Optimal Level of Mobility:
The nurse should help active or passive
range of motion every 6-8 hours to
prevent contractures and venous stasis.
71Prof. Dr. RS Mehta, BPKIHS

72. Promoting Optimal Communication:
Assessment of the ability of the ventilator-
dependent patient's to communicate and thus
identify the patient's limitations.
Use non-verbal methods of communication.
Use of signals, signs, nodding, palm writing, lip
reading.
Provide paper & pencil, magic slate.
Be alert to non-verbal clues.
Allow patient to respond and repeat
explanations.
72Prof. Dr. RS Mehta, BPKIHS

73. Preventing trauma and infections:
Positioning of the ventilator tubing
should be such that there is minimal
pulling or distortion of the tube in the
trachea to reduce the risk of trauma to
the trachea.
Monitoring of cuff pressure every 8 hrs
to maintain the pressure less than 25cm
of H2O.
Tracheotomy care at least every 8
hourly & more frequent if need.
73Prof. Dr. RS Mehta, BPKIHS

74. Preventing trauma and infections…
Oral care frequently because the oral cavity is
the primary source of contamination of the
lungs in the intubatedand compromised
patients.
The naso-gastric tube can increase the risk
of aspiration, leading to nosocomial
pneumonia hence the patient should be
positioned with the head elevated above the
stomach.
All prescribed medications should be given on
time.
Prof. Dr. RS Mehta, BPKIHS 74

75. Promoting coping Ability:
Encouraging family to verbalize their
feelings about the ventilators, patient's
condition is beneficial.
Explanation about the procedures every
time they are performed helps to reduce
anxiety.
75Prof. Dr. RS Mehta, BPKIHS

76. Rest & Sleep:
Keep calm & quiet environment.
Turn monitor alarm down if possible.
Provide dim light during night & soft music
if possible.
Cover patient eyes with clean gauze.
76Prof. Dr. RS Mehta, BPKIHS

77. Oral Hygiene:
Provide oral care every 2 hourly as oral mucus
membranes dry in 2 hours.
Moisten the mouth with solutions that do not
contain alcohol or lemon. Moistens the lips with
lubricant. It prevents drying, cracking &
excoriation.
Brush the client’s teeth as twice daily as dental
caries are prevented by saliva.
Suction oral secretions from the mouth as
secretions pool in oro-pharynx because of the
inflated tracheal cuff.
Assess for pressure areas at the corner of the
mouth.
77Prof. Dr. RS Mehta, BPKIHS

78. SAFETY & SECURITY NEEDS
Secure physically, mentally, emotionally.
Prevent trauma & infection
Perform hand-hygiene & adopt sterile
techniques.
Prevention of cross-infection & nosocomial
infection.
Maintain warm & adequate body temperature.
Put side-rails.
Visiting hours should be defined.
78Prof. Dr. RS Mehta, BPKIHS

79. ARTIFICIAL AIRWAY:
1.COMBITUBE.
2.LMA (Laryngeal Mask Airway)
3.OROPHARYNGEAL airway
4.NASOPHARYNGEAL airway
5.ETT
6.TRACHEOSOTOMY tube.
79
Prof. Dr. RS Mehta, BPKIHS

80. 0ropharyngealAirway:
ThereareA.A.with
length25-35cm,sized
5-10mm(acco.Int.
diameter),vol.capacity
ofETtubeisfrom35-
45ml(whichisabt.
Abouthalfthevol.of
anatomicaldeadspace
inadults1ml/kg).
80Prof. Dr. RS Mehta, BPKIHS

81. THANK YOU!!!
81
Prof. Dr. RS Mehta, BPKIHS