Care of patient on mechanical ventilator.pptx

For advanced education

1. Care of patient on Mechanical Ventilator ANEETTA BABU Staff Nurse-Critical Care

2. Topic Includes

3. Introduction What is ventilator? Patient might present with respiratory failure, thus requiring invasive mechanical ventilation (MV) to help or replace spontaneous breathing.

4. Definition Mechanical ventilation (MV) works by applying a positive pressure breath and is dependent on the compliance and resistance of the airway system. Mechanical ventilators are mainly used in hospitals and transport system such as ambulances .They can be used at home incase of long-term illness. (Tracheostomized)

5. Purpose

6. Indications Respiratory failure. Major surgeries like CABG, HIP replacement, organ transplant . Upper and lower Airway Obstruction. Neuro muscular disease like myasthenia gravies ,Guillain barre syndrome, Polio myelitis Cardiac arrest. Lung disease like Chest injury, Pneumothorax, COPD, ARDS/ NRDS. CNS disease like cerebrovascular accident , seizure, cerebral aneurysm, Head injury. Other cases like poison, drowning, Inadequate reversal of anesthesia.

7. Types

8. Types (Continues) Invasive Positive pressure delivered to the patient’s lung via ET tube or tracheostomy tube . Invasive mechanical ventilation (IMV) is usually initiated in the operating room, emergency room, or intensive care unit Insertion of the airway generally requires sedation, and the indications necessitate a monitored setting for care. eg .,The patient who have COPD with severe hypoxia and acidosis, who is unsuitable for non-invasive needs mechanical ventilator. Non-invasive It's a ventilatory support that provided via a face mask to the patient's upper airway . e.g., It's used for both acute and chronic respiratory failure, but need more close monitoring.

9. Parameters of the ventilator Fraction of inspired oxygen (FiO2): delivered in the inspiratory gas mixture, expressed as a decimal fraction. FiO2 can range from 21% (room air) to up to 100% (pure oxygen). Respiratory Rate/Frequency (RR or F)  in respirations per minute; this may be the patient’s intrinsic rate or set using the ventilator.

10. Parameters of the ventilator Tidal volume (Vt): Is the amount of air that moves in or out of the lungs with each respiratory cycle. It measures around 500 mL in an average healthy adult male and approximately 400 mL in a healthy female. Positive End-Expiratory Pressure Pressure given in expiratory phase to prevent closure of the alveoli and allow increased time for O2 exchange Used in pts who haven’t responded to treatment and are requiring high amount of FiO2 PEEP will lower O2 requirements by recruiting more surface area Normal PEEP is approximately 5cmH20. Can be as high as 20cmH20

11. Parameters of the ventilator Inspiratory time ( Ti ) the inspiratory time is the amount of time it takes to deliver the tidal volume of air to the lung. The ratio of inspiratory time to expiratory time is a vital indication of respiration quality and is directly related to the respiration rate.

12. Modes of ventilators Controlled modes Supported modes Combined modes Spontaneous breathing VC PS VC – VS CPAP PC VS PC – PS Nasal CPAP PRVC NIV- PS PRVC – VS BiPAP NIV – PC SIMV : VC + PS SIMV : PC + PS SIMV : PRVC + PS

13. Modes of ventilator (Continue..) Volume control mode( VC ) P reset tidal volume is delivered at a set rate, primarily used when the patient has no spontaneous breathing. Pressure control(PC) The ventilator delivers a breath to a set pressure and set rate . This is primarily used when the patient has no spontaneous breathing but will support the patient if they are able to trigger a breath. Pressure regulated volume control (PRVC) It is a controlled mode of ventilation which combines pressure and volume. A preset tidal volume is delivered at set rate like VC, but it's delivered with the lowest possible pressure.

14. Modes of ventilator (Continue..) Synchronized intermitted mandatory ventilation ( SIMV) It’s a type of volume control mode of ventilation . The ventilator will deliver a mandatory set numbers of breaths with a set volume ,while at the same time allowing spontaneous breath . e.g.; patient take a breath and the ventilator adds pressure to the breath to make it easier for the patient to achieve a good tidal volume Pressure support (PS) Pressure support provide support for every patient triggered breath. It is used for patients who don’t have sufficient capacity or facilities weaning. The patient initiates a breath, and the ventilator delivers support with the preset pressure level above peep. With the support of ventilator , the patient regulates the respiratory rate and tidal volume.

15. Modes of ventilator (Continue..) Volume Support(VS) Its works in a very similar way to pressure support but tidal volume and peep are set rather than pressure. The patient initiates the breath, and the ventilator delivers support in proportion to the inspiratory effort and the target volume. The set tidal volume is delivered to the patient with different support from the ventilator depending on the patient’s activity.

16. Modes of ventilator (Continue..) Nasal CPAP Nasal CPAP can be delivered oxygen through nasopharyngeal tube, nasal mask or nasal prongs on infants from 500g to 10kg . The CPAP level and oxygen concentration is set, and the ventilator will deliver the flow necessary to maintain the desired pressure compensating for the leak ( maximum flow is 33L\min). Continue mandatory ventilation( CMV) The mode described were all the patient’s breath are being provided by the ventilator . e.g. ; The patient is sedated all breath are triggered ,limited and cycled by the ventilator.

17. Modes of ventilator (Continue..) Non- invasive ventilation (NIV) The delivery of oxygen (ventilator support)via a face mask and there for eliminating the need of an endotracheal airway . The patient must be conscious and breathing spontaneously . The patient must have an adequate gag and cough reflex . NIV–Pressure control In this controlled mode of ventilation ,ventilator deliverers a flow to maintain the preset pressure at a set respiratory rate and inspiratory time (like invasive pc). The patient can also trigger a controlled breath.

18. Modes of ventilator (Continue..) NIV–Pressure Support In this spontaneous mode of ventilation were the patient initiates the breath and the ventilator delivered support with the preset pressure level. The patient regulates the respiratory rate and tidal volume so the alarm parameters must be set appropriately.

19. The following guidelines are recommended

20. The following guidelines are recommended (Continue..)

21. Ventilator alarms and causes Alarm Definition Potential Causes High Pressure Pressure required to ventilate exceeds present pressure. Pneumothorax , excessive secretions, decreased lung compliance. Low pressure Resistance to inspiratory flow is less than preset pressure. Disconnected from ventilator, break in circuit. Low exhaled volume Exhaled tidal volume drops below preset amount. Leak in system, increased airway resistance decreased lung compliance. Rate/apnea Respiratory rate drops below present level. Apnea period exceeds set time. Client fatigue, decreased RR due to medication. FIO2 Indicates FIO2 drift from present range. Change in level of consciousness, disconnected from O2 source, break in circuit.

22. Ventilator alarms and causes General principles… Look at the patient first!!! Then follow tubing to the vent to search for any disconnections. If can’t find the problem and the patient is in distress, disconnect the patient from the vent and bag with 100% O2 (and call for help).

23. Essential care for ventilator patients Assess the patient condition Manage airway Suction appropriately Check the ventilator setting and modes Meet the patient's physiological needs Provide psychological support to patient's and family Abide with VAP bundle. Review communication Prevent hemodynamic instability Monitor GI bleeding Prevent complication of ventilator

24. Essential care for ventilator patients (Continue..) Assess the patient condition Assess patient's level of pain ,anxiety level and sedation needs. Monitor vital signs. Monitor for airway obstruction ,ineffective breathing pattern, ET tube Kinking etc. Check oxygen saturation ,listen to breath sounds and note changes from previous findings.

25. Essential care for ventilator patients (Continue..) Manage Airway Assess respiratory rate and depth. Assess patient for oxygenation and signs and symptoms of hypoxia. Elevate the head of bed. Proper cuff inflation ensure the patient receives proper ventilator parameters ,such as proper oxygenation and tidal volume. Never add air to the cuff without using proper techniques. Performing suction and oral care ,ensure the patient got cleared the airway. Provide chest physiotherapy and breathing exercises for secretion mobilization.

26. Essential care for ventilator patients (Continue..)

27. Essential care for ventilator patients (Continue..) Check ventilator setting and modes Read the patients order and obtain information about the ventilator. compare current ventilator settings with the settings prescribed in the order. Check type of ventilator, controlling mode, tidal volume and rate settings, FiO2 setting, inspiratory to expiratory ratio, inspiratory pressure, PEEP, humidifier etc. Familiarize yourself with ventilator alarms and the action to take when an alarm sounds.

28. Care of essential for ventilator patients (continue..) Meet the patient's physiological needs Provide eye, oral care and moisten the lips with lubricant. Maintain hygiene of the patient. Administer Naso -gastric tube feeding as ordered. If NG tube feeding is not possible, administer parenteral nutrition. Address the patient's elimination needs. Provide catheter care. Keep quiet and calm environment to promote rest and sleep. Keep monitor alarm down if possible. Provide dim light at night. Provide patients eye with eye patch.

29. Essential care for ventilator patients (Continue..) Provide psychological support to patient's and family To ease distress patient and family , teach them why mechanical ventilation is needed and emphasize the positive outcome it can provide . Encourage family members to verbalize their feelings about the ventilators, patient condition. Explain the procedures to the patient and family each time. Reinforce the need and reason for multiple assessment and procedures, such as laboratory test and x-rays. Communicate desired outcomes and progression toward outcomes so the patient and family can actively participate in the plan of care. The nurse must be knowledgeable and confident while dealing with patient and his family members.

30. Essential care for ventilator patients (Continue..) Review communication Assess the ability of the ventilator-dependent patients to communicate. Be alert to non-verbal clues of the patient and use non-verbal methods of communication. Provide writing tools, communication board or call bell so patient can express their needs. Ask simple yes/no questions to which patient can nod or shake his/her head.

31. Essential care for ventilator patients (Continue..) Prevent hemodynamic instability Monitor the patient’s blood pressure every hour, especially after ventilator settings are changed or adjusted . To maintain hemodynamic stability , maintain iv fluids or administer a drug such as dopamine or norepinephrine , if doctor ordered. High levels of inspiratory pressure with PSV(Pressure support ventilation) and PEEP( Positive end-expiratory pressure) increase the risk of barotrauma and pneumothorax .To assess these complication oftenly check breath sounds and oxygenation status.

32. Essential care for ventilator patients (Continue..) Prevent complication of ventilator Wash hands and use appropriate personal protective equipment such as gloves, when touching patient's intubation tubes or ventilation. Keep the head of the bed elevated 30-45 degree at all time ,if patient condition allows. Provide oral care at least twice a day and provide oral moisturizes every 2 to 4 hours. Observe skin for pressure sores, provide back care, use pressure relief matters and change the position of the patient frequently.

33. Essential care for ventilator patients (Continue..) Prevent complication of ventilator Provide deep vein thrombosis prophylaxis, as with an intermittent compression device. Provide range of motion exercise and patient turning and positioning to prevent the effects of muscle disuse. Monitor GI bleeding Monitor bowel sound. Monitor gastric PH and hematemesis gastric secretions every shift.

34. Essential care for ventilator patients (Continue..) Wean the patient from the ventilator appropriately As your patient’s indication for mechanical ventilator resolve and she or he can take more breath by itself ,the healthcare team will consider remove the patient's ventilator. Some patients may need weak of gradually reduce ventilator assistance before extubated ,but some can’t be weaned at all . Main factors that affect of weaning include underlying disease process, such as COPD or peripheral vascular disease .

35. Complication Intubation related Hypoxia Esophageal intubation Upper airway trauma Hypotension Aspiration Cuff leak, sinusitis Upper airway stenosis Self extubation Ventilator related Disconnection, malfunction Suction related Hypoxemia Arrhythmia Ventilation related Nosocomial infection Hemodynamic effect Pneumothorax Respiratory alkalosis Increased ICP

36. Weaning Process Adequate Oxygenation: PaO2 >60-70 on FiO2 40% to 50%, PEEP 5-8cmH20 PaO2/FiO2 ratio >150-200 Adequate Ventilation: PaCO2 35-45mmHg PH 7.3 to 7.45 Adequate Respiratory Mechanics: Tidal Volume Respiratory Capacity Minute Ventilation Hemodynamic Stability. Spontaneous Breathing Trials (SBT).

37. References Invasive mechanical ventilation . (n.d.). https://empendium.com/mcmtextbook/chapter/B31.IV.24.67.1. Ccaa , M. B. B. R. (n.d.). I:E Ratio. Pressbooks. https://ecampusontario.pressbooks.pub/mechanicalventilators/chapter/ie-ratio/ Clini , E & Ambrosino, N. (2005, Sep). Early physiotherapy in the respiratory intensive care unit. Respiratory Medicine, (9):1096-104. ScienceDirect.com | Science, health and medical journals, full text articles and books. (n.d.-b). John Hopkins