ACCESS - CE- 2024 08 Z-Vent presentation.pptx

Updated **DRAFT** inservice for the Zoll Z Vent

1. Zoll Z Vent: Initial Mechanical Ventilation Training A.C.C.E.S.S. Education

2. Objectives How can I “Speak Vent” when I talk to other medical professionals? Review Common Ventilator related terminology How does mechanical ventilation affect the patient? Discuss the clinical implications of mechanical ventilation. What are all the things that the Z Vent can do? Describe the features of the Zoll Z Vent. Discuss the ventilator modes of operation What are the permitted uses if the Z Vent in the ACCESS system? Review the pertinent ACCESS protocols and procedures. I think I need to practice with the Z Vent. Demonstrate the application of the Z vent in a simulated patient scenario. 2

3. Ventilator Terminology Review Common Ventilator related terminology

4. Tidal Volume ( Vt ) and Minute Volume ( Mv ) Tidal Volume (Vt): The volume (measured in cc) of air delivered with each breath . The appropriate tidal volume depends on numerous factors, most notably the patient’s ideal body weight (IBW). Vt is based on IBW Minute Volume (Mv): The volume (measured in liters) of air delivered over a minute . Vt x BPM = Mv

5. Use Height (I/PBW) for Tidal Volume Adult Male Adult Female Pediatric

6. Brief Exercise (3 minutes) MV for 10 Breaths/minute and Vt 500 cc 5 liters / minute MV for 20 Breaths/minute and Vt 500 cc 10 liters a minute MV for 30 Breaths/minute and Vt 500 cc 15 liters a minute “I now appreciate that 15 Lpm via a non-rebreather mask may not meet the minute ventilation of patients in extremis; this explains how a non-rebreather can collapse with inspiration and why many patients feel suffocated with a mask over their face.” (Levitan, 2015)

7. Fraction of Inspired Oxygen (FIO 2 ) Fraction of Delivered Oxygen (FDO 2 ) FIO2 The lowest possible fraction of inspired oxygen ( FIO2 ) necessary to meet oxygenation goals should be used. This will decrease the likelihood that adverse consequences of supplemental oxygen will develop, such as absorption atelectasis, accentuation of hypercapnia, airway injury, and parenchymal injury Start at 100% FIO2 and titrate to main SpO2 at (94% - 99%) FDO2 fractional delivered oxygen, and it describes the amount of oxygen that reaches the body's capillary beds and perfuses its cells. FdO2 is a factor that determines oxygenation,

8. Dead Space Volume of a breath or ventilation that does not participate in gas exchange. Total Dead Space has 3 components Anatomic / Physiologic - (approximately 2ml/kg) Mechanical - (equipment dependent)

9. Dead Space

10. Dead Space Dead Space increases the required Tidal Volume Dead Space increases retained CO2

11. Setting up the Z Vent Discuss the clinical implications of mechanical ventilation.

12. Zoll Z Vent - Overview & Specs Size: 8 x 12.5 in Weight: 9.7 lbs. (4.4 kg) Compressor-Driven No “Bias Flow”. Does not require oxygen to operate (1/3 less O2 used) FiO2: 21% to 100% Range: Supports Patients 5kg and Above

13. Zoll Z Vent - Overview & Specs Operating Temperatures: -25 to 49 C (-13 to 120 F) Altitude Compensation: -2,000 ft. to 25,000 ft. (-610 m to 7,620 m) Meets Military Specifications IP X4: Impervious to jetting water Meets military dust/dirt standards

14. Making Yourself Successful Checking Your Equipment ET Tubes Vent Circuit Continuing Patient Care Changing Vents – Confirm Settings Treatment History Positioning Your Patient Pseudo-Normalization Utilizing Hospital Equipment Non-Invasive Masks (Vented v/s Non-Vented)

15. SpO2 and Charging

16. Charging & Caution Battery: 10 Hour battery run time ACP will charge at 50% Fully charged in 2 hours

17. Important Point The power cable connection is one of the most fragile parts of the Zoll Z Vent® . Please treat with care.

18. Adult vs Pedi Circuits Top view Ventilator Setup Vt: 200ml to 2000ml (20kg and >) Vt: 50ml to 300ml (5kg to 30kg) Oxygen Input (High/Low) Airway Pressure Transducer Exhalation Valve Gas Output

19. Where to put the HEPA Filter?

20. Where to put the HEPA Filter?

21. Fresh Gas / Emergency Air Intake

22. Parameter and MENU Buttons NO!!! Yes!!!

23. Parameter and MENU Buttons Primary Parameters Single Press Secondary Parameters Multiple Presses Context Menus Press and Hold

24. Ventilator Start Up Sequence Vent Book Start-Up Process Start Menu

25. Ventilator Start Up Sequence

26. Touch - Turn - Confirm Touch – The Parameter Buttons Turn - The Dial to Adjust the Value Confirm - To Make the Change

27. Alarms Red: High Priority Yellow: Low Priority Green: No Alarm / Normal Operations No Audio Alarm for first 2 min Cancel Button will silence alarms (30s) Bells signify alarm parameters High and Low values can be changed .

28. Start Menu Adult Pediatric Mask CPAP Custom Last Settings

29. Smart Help SmartHelp TM On-screen prompts guide users through alarm resolution Critical Controls on One Screen No need to toggle through multiple screens to change primary parameters or monitor patient status Digital LCD, rather than analog controls, for precision and ease of use

30. Pop-Up Messages

31. Remember 1. First conduct the "Ventilator Operational Test" 2. THEN Set patient-specific settings 3. Visually confirm proper functioning by attaching to a test lung prior to attaching to the patient.

32. When in doubt….

33. Intermission

34. Basic Functions of the Z Vent

35. Start Menu Adult Pediatric Mask CPAP Custom Last Settings

36. HR and SPO2 Not used in the ACCESS system Use the Monitor instead

37. FIO 2 : Oxygen Concentration “Fraction of inspired oxygen” Zoll Z Vent: measured as a % ACCESS Protocols start at 100% and titrated to 50% Exception: Matching pre-existing settings

38. PIP: Peak Inspiratory Pressure The highest level of pressure applied to the lungs during inhalation. PIP is the combination of the PEEP and pressure above PEEP PIP is set in pressure modes PIP is measured in volume modes

39. PIP Alarms Standard alarm settings should be: High pressure alarm: 10 cmH2O above peak airway pressure. Low pressure alarm: 5 cmH2O below peak airway pressure.

40. PEEP: Peak Inspiratory Pressure PIP is the combination of the PEEP and pressure above PEEP PIP is set in pressure modes PIP is measured in volume modes Defaults to 5 cmH2O

41. https://www.youtube.com/watch?v=CDEYWok94uQ&t=2s

42. Vt: Tidal Volume The amount of air delivered with each breath. Vt is set in volume modes Based on predicted ideal body weight (IBW). Usual Vt: 6-8 ml/Kg depending on disease state and protocols Vt is measured in pressure modes.

43. BPM: Breaths per minute For most adult patients, a respiratory rate between 10 and 16 breaths per minute is a reasonable starting point Standard Rages are noted in the vent book

44. BPM Alarms In invasive ventilation ( A/C V and SIMV ), a high respiratory rate alarm may indicate poor sedation or a too sensitive trigger. In non-invasive ventilation ( cpap and bipap ) you may have to adjust upper alarm limits due to pt’s resp. distress.

45. Inspiratory Time (Ti or I-Time) Inspiratory Time ( Ti or I-Time) The time of the breath where the patient is inhaling or the time it takes to deliver the set Tidal Volume (VT). Increasing the inspiratory time can give the Patient a longer time to get air and O2 in and improve oxygenation & ventilation Too long of an inspiratory time may inhibit exhalation and cause the CO2 to rise (monitor EtCO2 ) Affected by r esp rate

46. Inspiratory and Expiratory Time (I:E Ratio) During spontaneous breathing, the normal I:E ratio is 1:2.5 indicating that for normal patients the exhalation time is about twice as long as inhalation time. If exhalation time is too short “breath stacking” occurs resulting in an increase in end-expiratory pressure also called auto-PEEP. Ti : 1.25 Te : 3.75 Ti + Te = 5 sec

47. I: E Ratio Inspiration 1 Seconds Exhalation 2 Seconds I:E Ratio of 1:2

48. Oxygenation and Ventilation Need to improve Oxygenation?  PEEP + FIO2 Need to improve Ventilation?  Vt + BPM Trapping Air?  Increase Exhalation (I:E Ratio)

49. Rise Time (RT ) The speed at which inspiratory pressure increases, to reach the set target pressure (PIP). Adjustments in rise time can improve patient comfort/tolerability with Non-Invasive modes. Rise times generally go from 100ms to 600ms, with settings of 1 through 10 2.0 is default

50. Trigger Level The amount of negative pressure a patient must generate to get a breath delivered. Triggering, can be either time or patient cycling. Can be set from -0.5 cmH2O to -6.0 cmH2O -0.5 is the easiest for the patient to initiate and -6.0 is the hardest. -2.0 is default

51. Cycle Percent The event that ends the inspiratory time, and exhalation begins. Like triggering there can be either time or patient driven. 25% is default

52. Plateau Pressure The plateau pressure is measured at end-inspiration ( no flow ) by pressing P-PLAT 0.5 to 1 second. Should be <30 cm H2O Should stay consistent

53. Plateau Pressure Plateau Pressure = End of Flow/Compliance Peak Pressure = Airflow/Airways PEEP of 5 cm H2O

54. PIP vs. PEEP vs. Pplat PEEP of 5 cm H2O

55. Name 1 of the 3 Hidden functions and where can they be Found? FIO2 O2 Reservoir PIP Trigger BPM Control Parameter Cycle Off % Spont . Ti Limit

56. Intermission

57. Modes of Operation

58. Modes of Operation

59. Modes: Volume v/s Pressure Pressure Targeted Modes Pressure Set Volume Variable Volume Targeted Modes Volume set Pressure Variable

60. “Pressure targeted"  breathing modes are NOT approved functions for ACCESS providers. These modes require an RT (or similar) to attend.

61. Modes: CMV Controlled Mandatory Ventilation

62. Modes: CMV (V) Even though a breath trigger is attempted, there is no “assist” from the vent.

63. Modes: A/C (V) ALL breaths are the same set volume

64. Modes: SIMV (V) trigger Full Volume “Synchronized” Breath

65. CPAP and Bi-Level Modes CPAP 2-5 cmH2O, Titrated to 10 cmH2O Bi-Level ePAP : 3-10 cm H2O iPAP : 9-20 cm H2O iPAP is always 5-10 cm H2O > ePAP Z-Vent provides : Leak compensation during noninvasive ventilation Tubing compliance compensation

66. CPAP and Bi-Level Modes CPAP Constant Positive Pressure Bi-Level Inhalation and Exhalation Pressures CPAP and BL are intended for ventilatory support, NOT ventilation.

67. In-Line Nebulized Treatment 80 cc

68. Cardiac Arrest – Custom Setting

69. D O P E R S

70. Documentation

71. Questions?

72. Scenario Review

73. Scenario #1 Disp. to prison for Low SPO2, arrived to find pt. in cardiac arrest. Recent Hx of Pneumonia No other Hx Pt Defib x1, CPR, ETT, In line suction and neb. POST-ROSC you decide to place the patient on the vent. 76

74. Scenario #1 Pt is estimated at 5’10, 200 lbs What is your starting: FIO2 PEEP Vt BPM I:E Preferred Mode

75. Scenario #1 Pt is estimated at 5’10, 200 lbs B/P 100/40 HR 128 Resp 4 spont . + Ventilation What is your : POST ETT/ROSC Sedation? Other Concerns?

76. Scenario #1 During transport: SPO2 72% and dropping. HR is 52/min and dropping. ETCO2 is 24mmHg and dropping. What is your first steps?

77. Scenario #1 During transport: Pt Rearrests What is your next steps?

78. Now to Skills…