care of child on ventilator

mechanical ventilation and care of child on it

1. Care of child requiring long term ventilation Moderator : Mrs. Kiran K aur Junior Lecturer, C.O.N PGIMS, Rohtak Presenter :Aruna Shastri M.Sc. 2 nd year student

2. OBJECTIVES Incidence of continuous ventilation Goals of mechanical ventilation. Classification of different modes of ventilation. Adjustment on the ventilator. Guidelines recommended during mechanical ventilation Monitoring child with continuous ventilation Weaning from the ventilation. Monitoring child with non-invasive oxygen therapy. Complication of continuous ventilation. Nursing management of ventilated patient.

3. Introduction: Children who are long-term ventilated have been found to have a significantly health-related poor quality of life. Children and young people on long-term ventilation require the most complex care that is given outside a hospital environment and there are significant risks involved in looking after a child on long-term ventilation in the community. Competencies and training needed is also a major concern for long term ventilation.

4. Incidence Significant rise in number of children on long term ventilation - (Wallis et al 2010, Goodwin et al 2011) The need for long term ventilation to discharge home is an average of 7-9 months The number of tracheostomy ventilated children managed out of hospital is approximately 250-275 per 10000 1000-1300 children with complex needs dependent upon non-invasive ventilation under specialist respiratory follow-up. Currently the financial cost of the hospital for recent onset complex long term ventilation is high -Pediatric Critical Care Clinical Reference Group (CRG)

5. Normal respiration : Exchange of oxygen ( O2 ) and carbon dioxide (CO2) between the lungs and the external environment

6. Difference in pediatric and adult respiratory system

7. Respiratory Failure •Inability of the pulmonary system to meet the metabolic demands of the body through adequate gas exchange. Two types of respiratory failure:  Hypoxemic Hypercarbic •Each can be acute and chronic. •Both can be present in the same patient. •Management of this condition required assisted mechanical ventilation

8. Mechanical ventilation Mechanical ventilation can be defined as the technique through which gas is moved toward and from the lungs through an external device connected directly to the patient. Mechanical ventilation  is the  medical  term for  artificial ventilation  where mechanical means is used to assist or replace spontaneous  breathing

9. Indication for mechanical ventilation in children Apnoea with respiratory arrest Acute respiratory acidosis with paCO 2 > 50 mmHg & pH < 7.25 Hypoxemia with PaO 2 <50 mm Hg with FiO 2 > 60% Vital capacity <2 times tidal volume RR> 35/min Acute lung injury (including ARDS, trauma) Obstructive diseases like Asthma Hypotension including sepsis, shock, CHF Neurological diseases such as GB syndrome.

10. Functions Achieve and maintain adequate pulmonary gas exchange Minimize the risk of lung injury Reduce patient work of breathing Optimize patient comfort To normalize blood gases and provide comfortable breathing To maintain sufficient oxygenation and ventilation. To provide safe environment for the patient while protecting the lungs from damage due to oxygen toxicity, pressure.

11. Definitions Tidal Volume (TV): volume of each breath. Rate: Breaths per minute. Minute Ventilation (MV): total ventilation per minute. MV = TV x Rate. Flow: volume of gas per time. Compliance: the distensibility of a system. The higher the compliance, the easier it is to inflate the lungs. Resistance: impediment to airflow.

12. Definitions PIP: Maximum pressure measured by the ventilator during inspiration. PEEP: Pressure present in the airways at the end of expiration. CPAP: Amount of pressure applied to the airway during all phases of the respiratory cycle. PS: Amount of pressure applied to the airway during spontaneous inspiration by the patient. I-time: Amount of time delegated to inspiration . SIMV : Patient breathes spontaneously between ventilator breaths. Allows patient-ventilator synchrony, making for a more comfortable experience.

13. Types of ventilation 1. Positive pressure ventilation. Volume cycled Pressure cycled Time cycled 2. Negative pressure ventilation.

14. MODES Volume cycled Controlled Mandatory ventilation Assist-Control Ventilation Intermittent Mandatory Ventilation (IMV) Synchronous Intermittent Mandatory Ventilation (SIMV) Pressure cycled Pressure Control Ventilation (PCV) Pressure Support Ventilation (PSV) PEEP (Positive End Expiratory Pressure) CPAP (Continuous Positive Airway Pressure) BiPAP ( Bilevel Positive Airway Pressure)  

15. Ventilator mode Volume control Pressure Control Pressure Support-CPAP Pressure-Regulated Volume Control

16. Volume Control The patient is given a specific volume of air during inspiration. The ventilator uses a set flow for a set period of time to deliver the volume. The PIP observed is a product of the lung compliance, airway resistance and flow rate. The PIP tends to be higher than during pressure control ventilation to deliver the same volume of air.

17. Pressure Control Patient receives a breath at a fixed airway pressure. The ventilator adjusts the flow to maintain the pressure. Flow decreases throughout the inspiratory cycle. The pressure is constant throughout inspiration. Volume delivered depends upon the inspiratory pressure, I-time, pulmonary compliance and airway resistance. The delivered volume can vary from breath-to-breath depending upon the factors.

18. Comparison of ‘volume-controlled’ and ‘pressure-controlled’ breaths

19. CPAP-Pressure Support No mandatory breaths. Patient sets the rate, I-time, and respiratory effort. CPAP performs the same function as PEEP, except that it is constant throughout the inspiratory and expiratory cycle. Pressure Support (PS) helps to overcome airway resistance and inadequate pulmonary effort and is added on top of the CPAP during inspiration.

20. Modes of Ventilation: Controlled: The machine controls the patient ventilation according to set tidal volume and respiratory rate . spontaneous respiratory effort of Pt. is locked out, ( patient who receives sedation and paralyzing drugs he will on controlled Mode). Assist/control: The Pt. triggers the machine with negative inspiratory effort. If the Pt. fails to breath the machine will deliver a controlled breath at a minimum rate and volume already set.

21. Modes of Ventilation: SIMV:   Machine allows the Pt to breath spontaneously while providing preset FIO2, and a number of ventilator breaths to ensure adequate ventilation without fatigue. SIMV can be volume or pressure controlled. Spontaneous : The machine is not giving pressure breath. The Pt. breath spontaneously. The Pt. needs only specific FIO2 to maintain its normal blood gases.

22. Initial Ventilator Settings Rate: 20-24 for infants and preschoolers16-20 for grade school kids 12-16 for adolescents. TV: 10-15ml/kg PEEP: 3-5cm H 2 O FiO 2 : 100% I-time: 0.7 sec for higher rates, 1sec for lower rates. PIP (for pressure control): about 24cm H 2 O. Pressure Support: 5-10cm H 2 O.

23. Adjusting The Ventilator pCO 2 too high pCO 2 too low pO 2 too high pO 2 too low PIP too high

24. The Following Guidelines are Recommended Set the machine to deliver the required tidal volume ( 6 to 8 ml/kg) Adjust the machine to deliver the lowest concentration of the oxygen to maintain normal PaO2 (80 to 100mmhg).The setting may be set high and gradually reduced based on ABGs result. Record peak inspiratory pressure. Set mode (assist/control or SIMV)and rate according to physician order. If Pt. is on assist/control mode , adjust sensitivity so that the Pt. can trigger the ventilator with the minimum effort( usually 2mmHg negative inspiratory force)

25. The Following Guidelines :are Recommended 6. Record minute volume and measure carbon dioxide partial pressure PaCO2, PH after 20 minutes of mechanical ventilation. 7. Adjust FIO2 and rate according to results of ABG to provide normal values or those set by the physician. 8. In case of sudden onset of confusion , agitation or unexplained " bucking the ventilator " the Pt. should be assessed for hypoxemia and manually ventilated on 100% oxygen with resuscitation bag ( AMBU bag) Bag – Valve – mask. 9. Patient who are on controlled ventilation and have spontaneous respiration may " fight or buck " the ventilator, because they cannot synchronize their own respiration with the machine cycle.

26. Weaning Priorities Wean PIP to <35cm H 2 O Wean FiO 2 to <40% Wean PEEP to <8cm H 2 O Wean PEEP, PIP, I-time, and rate towards extubating settings.

27. SEDATION & MUSCLE RELAXANTS Midazolam 50-150 mcg/kg IV q1-2hr PRN   1-2 mcg/kg/min IV infusion <32 weeks gestation: 0.5 mcg/kg/min IV infusion   Vecuronium 1-10 years old 0.1 mg/kg IVP; repeat q1hour PRN; OR   Continuous Infusion: 0.05-0.07 mg/kg/hour IV Succinyl choline Loading dose 1-2 mg/kg IV x1 dose   3-4 mg/kg deep IM x1 dose (no adequate IV) Maintenance dose 0.3-0.6 mg/kg IV q5-10min PRN Fentanyl 0.5-2 mcg/kg/dose IV q1-2hr

28. Extubation Criteria Neurologic Cardiovascular Pulmonary

29. Neurologic Patient must be able to protect his airway, e.g , have cough, gag, and swallow reflexes. Level of sedation should be low enough that the patient doesn’t become apneic once the ETT is removed. No apnea on the ventilator. Must be strong enough to generate a spontaneous TV Being able to follow commands is preferred.

30. Cardiovascular Patient must be able to increase cardiac output to meet demands of work of breathing. Patient should have evidence of adequate cardiac output without being on significant inotropic support. Patient must be hemodynamically stable.

31. Pulmonary Patient should have a patent airway. Pulmonary compliance and resistance should be near normal. Patient should have normal blood gas and work-of-breathing on the following settings: FiO 2 <40% PEEP 3-5cm H 2 O Rate: 6bpm for infants, 2bpm for toddlers, CPAP/PS for 1hr for older children and adolescents PS 5-8cm H 2 O Spontaneous TV of 5-7ml/kg

32. ABG ABG analysis is the gold standard for monitoring the adequacy of gas exchange • SpO2 targets of 85-93% is the most appropriate. • In term and near term infants and older children who are mechanically ventilated it is acceptable to target SpO2 between 92-95 % and in children with cyanotic CHD SpO2 between 70 -75% are acceptable if tissue oxygenation is good.

33. Respiratory Disturbances Acute respiratory acidosis occurs when CO 2 is retained acutely. Chronic respiratory acidosis occurs when the retained CO 2 gets buffered by renal retention of HCO 3 . The pH is higher than in acute respiratory acidosis, but it is still <7.4.

34. Chest radiograph: The findings to look for: Position of the ET, central lines and umbilical catheters. Optimal positioning for ETT is approximately 1 -1.5 cm above the carina. Displacement of the tube into the oesophagus is indicated by a low ETT position. Poor aeration of the lungs and gaseous distension of the GI tract Look for the atelectasis, flattening of the diaphragm and lung expansion reaching the tenth rib suggests over expansion and increased risk of pulmonary air leaks and lung injury.

35. Tube securing/ fixation of ET tube

36. ET SUCTIONING Indications for ET suctioning Presence of visible secretions in the tube Drop in oxygen saturation High pressure ventilator alarm Increase in respiratory rate and decrease in tidal volume. Suctioning is a PRN procedure

37. Post extubation management Close monitoring Every patient should be oxygenated post- extubation . Oxygenation and airway clearance This may include suctioning, bronchodilator therapy, diuresis, or Noninvasive positive pressure ventilation (NPPV) Devices that provide adequate oxygenation and comfort for the patient are preferred – low flow devices

38. Complications Pulmonary Barotrauma Ventilator-induced lung injury Nosocomial pneumonia Tracheal stenosis Tracheomalacia Pneumothorax Cardiac Myocardial ischemia Reduced cardiac output Gastrointestinal Ileus Hemorrhage Pneumoperiteneum Renal Fluid retention Nutritional Malnutrition Overfeeding

39. Troubleshooting mechanical ventilation DOPE D – DISPLACEMENT OF TUBE. O – OBSTRUCTION OF TUBE. P – PNEUMOTHORAX E – EQUIPMENT FAILURE

40. Care of child on ventilator is a Team approach include Physician Nursing staff Physiotherapist Respiratory physiotherapist(available in some selected tertiary centre )

41. Bundle is a structured way of improving the processes of care and patient outcomes. A small straightforward set of evidence –based practices-generally 3-5 that performed collectively and reliably, have been proven to improve patients outcomes,

42. Bundle can be used to ensure the delivery of minimum standard care. Used as a audit tool to assess the delivery of interventions. Most utilized bundle is sepsis care bundle worldwide.

43. VAP BUNDLE SEPSIS CARE BUNDLE CENTRAL LINE CARE BUNDLE

44. VAP BUNDLE

45. SEPSIS CARE BUNDLE 3-HOUR RESUSCITATION BUNDLE

46. SEPSIS CARE BUNDLE 6-HOUR RESUSCITATION BUNDLE

47. Nursing Management of Ventilated Patient Promote respiratory function. Monitor for complications Prevent infections. Provide adequate nutrition. Monitor GI bleeding.

48. 1. Promote respiratory function Auscultate lungs frequently to assess for abnormal sounds. Suction as needed. Turn and reposition every 2 hours. Secure ETT properly. Monitor ABG value and pulse oximetry.

49. Mobilize the secr e t i o n s Prevent pne u m o nia Reduce h o spi t al stay

50. Suction of an Artificial Airway To maintain a patent airway. 2. To improve gas exchange. 3. To obtain tracheal aspirate specimen. 4. To prevent effect of retained secretions. ( Its important to OXYGENATE before and after suctioning)

51. 2. Monitor for complications 1. Assess for possible early complications Rapid electrolyte changes. Severe alkalosis. Hypotension secondary to change in Cardiac output. 2. Monitor for signs of respiratory distress: Restlessness Apprehension Irritability and increase HR.

52. Monitor for complications 3. assess for signs and symptoms of barotrauma(rupture of the lungs) increasing dyspnea. Agitation. Decrease or absent breath sounds. Tracheal deviation away from affected side. Decreasing pao2 level . 4. Assess for cardiovascular depression: hypotension tachycardia and bradycardia dysrhythmias.

53. 3. Prevent infection 1. Maintain sterile technique when suctioning. 2. Monitor color, amount and consistency of sputum. 4. PROVIDE ADEQUATE NUTRITION Begin tube feeding as soon as it is evident the patient will remain on the ventilator for a long time. Weigh daily. 3. Monitor I&O . 5. MONITOR FOR GI BLEEDING Monitor bowel sounds. Monitor gastric PH and hematest gastric secretions every shift.

54. ORAL CARE: Tooth brushing twice a day Chlorhexidine rinse twice a day Munro CL, et al.(2006) found CHX significantly reduced VAP (24.4% vs. 52.4%, p =0.0093) compared with tooth brushing alone

55. EYE CARE: a) Ventilated patient is often sedated & Increase the risk of(muscle relaxed) Exposure keratitis Corneal ulceration Infection TT. Passive closure of eyelid, use lubricants, ( artificial tear. Prevention: eye packing, lubricating ointments and artificial tears, antibiotics eye drops)

56. SKIN CARE : Apply lotion to skin Prevent from decubitus ulcer formation Change position frequently Skin care to be given, massaging to be done to increase circulation Moisturizers Skin disinfectants(cause skin necrosis, blistering, burns) Povidone-iodine proved better than 70% isopropyl alcohol in pediatric patient.

57. NURSING DIAGNOSIS:- Ineffective airway clearance R/T ET obstruction * Suctioning sos * Watch for Resp. Distress, agitation or alteration in LOC . * Auscultate chest * Monitor Pao 2 & saturation * Ensure that inspired air is adequately humidified

58. NURSING DIAGNOSIS:- 2. Breathing pattern – ineffective R/T ventilator malfunction, inappropriate ventilator support. - Monitor patients color, responsiveness (LOC), Clinical appearance. - Asses patency & position of ET - Ensure the chest expands equally & bilaterally - Verify ventilator variables hourly. - Check connections of all tubing's hourly - Alarms should be active all times - Monitor PIP (  PIP  Pneumothorax)

59. NURSING DIAGNOSIS:- 3. Altered cardiac output R/T hypoxia * Monitor for adequate perfusion * Assess tube position & patency * Support CV function with fluids or with inotropic. * Monitor fluid balance daily (+ ve or – ve balance) 4. Alteration in nutrition less than body requirements R/T chronic Immobility. I.V,TPN, Plan calories & protein.

60. NURSING DIAGNOSIS:- 5 . a) Restlessness R/T hypoxia * Watch for pink lips & mucous membranes * Watch for bilateral chest expansion. * Watch for signs of hypoxia -  PR,  RR, alteration in systemic perfusion deterioration in LOC,  Sao 2 ,  Pao 2 - Nasal flaring,  Pul . Congestion,  breath sounds. - Check ventilator settings every hour. b) Restlessness due to constant stimulation - Provide comfortable bed & position - Allow for undisturbed sleep times - Reduce overhead lighting. - Minimize Environmental Noise.

61. NURSING DIAGNOSIS:- 6. Potential for impaired gas exchange R/T Atelectasis . * Auscultate breath sounds hrly * Check adequate PEEP is provided * Monitor for resp. distress * Give 100% O 2 before suctioning * Change position every 2 nd hrly. * Monitor regularly with chest x-ray & arterial blood gas. * Chest Physio hrly – cuffing, vibration

62. NURSING DIAGNOSIS:- 7. Potential for hypoxia R/T pul edema or damage to alveolar surface caused by barotraumas. * Fluid restriction * Monitor Sao 2 , capillary refill, Pao 2. * Auscultate lung every hour. 8. Potential for fluid vol excess R/T  levels of ADH secretion during ventilation at high peak or end exp. Pressure * Monitor I/O Chart * See + ve or – ve balance * Calculate Fluid requirement daily & administer. * Auscultate breath sounds for evidence of pul edema. * Aminister diuretics as ordered. * Monitor electrolyte balance

63. NURSING DIAGNOSIS:- 9. Potential for infection R/T a. bypass of normal body defense mechanism (upper airway) b. Break in aseptic technique during intubation & suctioning c. Repeated traumatic suctioning d. Compromise in nutritional status e. Underlying pulmonary disease * Assess for fever, leukocytosis (  WBC)  Respiration distress  Quantity or change in consistency of secretions,  pulmonary congestion by auscultation, & on chest x-ray. * Follow meticulous hand washing. * Aseptic technique during suctioning, intubation & change in ventilator circuit. * Monitor for WBC, platelet count for infection.

64. NURSING DIAGNOSIS:- 10. Potential for difficulty in weaning R/T failure of resolution of pul disease or due to nutritional compromise. * Monitor clinical appearance throughout. * Change only one parameter at a time. * Assisted ventilation should be ready during resp. distress

65. Conclusion Monitoring to optimize the respiratory support and limit the potential complications of ventilator induced lung injury, oxygen toxicity , air leaks and nosocomial infections. In acute intensive care units, more than one-fourth of patients with invasive ventilation required prolonged ventilation. Babies requiring mechanical ventilation require close observation

66. REFERENCES Smeltzer SC, Bare BG. Textbook of Medical Surgical Nursing 9th ed. USA :Lippincott William & Wilkins, 2000: 503-13 Paul L.Marino.The ICU Book 3rd ed.India : . Wolters Kluwer (India) Pvt Ltd/Lippincott Williams and Wilkins, 2009 http://en.wikipedia.org/wiki/Mechanical_ventilation Display&type = bookPage&d http://www.expertconsu kPage&search =none s0160%3Bfrom%3Dprev%3Btype%3Dboo http://www.respiratoryupdate.com/members/Indications_for_Neonatal_Mechanical_Ventil