Caring patient on Mechanical Ventilator

Mechanical ventilators are used now in general wards , not only in ICU -to save patient's life. We need to care patient and ventilator while working with it ..

1. By: Ms. Shanta Peter Caring patient on Mechanical Ventilator 1

2. Indications for Mech . Vent         PaO2 <50 mm Hg with FiO2 > 0.60 PaO2<50mmHg with pH <7.25 Vital Capacity <2 times TV Negative inspiratory force < 25 cm, H2O Respiratory > 35/min   2

3. Pt has continuous ↓ in oxygenation (PaO2 ) Increase in PaCO2 Persistent acidosis ( Decreased pH) Abdominal / Thorasic Surgery Drug overdose Neuromuscular disease Inhalation injury COPD Pt with apnea –not readily reversible Multiple trauma Multi system failure Coma All these will lead to Resp Failure 3

4. Mechanical ventilator … Nursing Interventions Unique technical and interpersonal skill Assess patient first then ventilator 4

5. GOAL Patient will be supported on mechanical ventilation without complication- then weaned , extubated . The complications will be detected, treated timely C/O patient on ventilator Detection Treatment Prevention Complications of Intubation & Mech. Ventilation Actual Patient Problems Eg .Infection Ventilator Problems 5

6. Two important Nsg interventions while caring a patent on ventilator are : Interpretation of ABG & Pulmonary Auscultation 6

7. General Nursing Interventions Assess for decreased cardiac output and administer appropriate Nursing Care Monitor for positive water balance – Pressure breathing may cause increase in ADH- Anti Diuretic Hormone and retention of wate r Auscultate chest for altered breath sounds -Take CVP /PCWP reading as ordered -Observe /assess for peripheral edema -Maintain accurate I & O -Assess Daily weights 7

8. Nsg Intervention .… Monitor for barotrauma – tension pneumothorax Assess ventilator checking every 4 hrs Auscultate breath sounds every 2 hrs Monitor ABGs Perform complete pulmonary-physical assessment every shift Monitor for GI problems- stress ulcer Administer muscle relaxants . tranquilizers, analgesics or paralyzing agents as ordered , to increase client machine synchronized by relaxing the client 8

9. Gas Exchange Judicious administration of analgesics without suppressing the respiratory drive Frequent re-positioning – to diminish pulm . effects of immobility Monitor adequate Fluid balance – observe peripheral edema, I& O chart, weight Pot. side effects of medications 9

10. Promoting Effective Airway C learance Positive pressure increase secretion Auscultate lungs Q2-4 hrs Suctioning – physiotherapy, position changes, - not as scheduled – but clinically related Observe for barotrauma/ pneumothorax Humidification – Bronchodilators, mucolytic agents – dilate bronchioles and liquefy secretions 10

11. Preventing trauma and infection Maintain ET /tracheostomy tube – position ventilator --- no pulling on tube Monitor cuff pressure Q8hrly – 25cm H2O Tracheostomy/tube care Q6hrs More care to immuno compromised patients Replace Vent Circuits/ inline suction tubing – as peer policy Oral hygiene NGT and use of antacids—cause nosocomial pneumonia from aspiration of tube feeding and gastric contents Semi-fowlers position 11

12. Promote optimal level of mobility When stable -after weaning -- assist him to sit up in chair Mobility of muscle activity – stimulate respiration and improve morale Active / passive ROM exercise if bed bound – prevent muscle atrophy , contractures and venous stasis 12

13. Promote optimal Communication Evaluate his abilities—Conscious?- can communicate ? he node or move hand ? Can he write? – right – left hand Understand patient 13

14. Promoting coping ability Encourage family to communicate – and verbalize fears Explain procedures every time to patient Restore sense of control- encourage to participate in his care Inform his progress – if long time on vent Stress reduction techniques – rubbing back , relaxation techniques …………… 14

15. Nurse should assess /monitor the ventilator Check type of ventilator —Volume cycled, Pres Cycled, - ve pres Controlling mode- ( Controlled vent, A/C , SIMV ) TV and rate settings- ( TV is usually 10-15 ml/Kg , rate 12-16;lmt FiO2 – (Fraction of inspired O2) – setting Inspiratory pressure reached and pressure limit ( normal 15- 20 cm of H2O (This increase in conditions where there is increased Airway resistance or decreased compliance) Sensitivity :( 2cm H2O Inspiratory force should trigger the ventilator 15

16. Ventilator… …. Insp to Exp Ratio(IE) usually 1:3 ( 1 second of insp to 3 sec of expiration) or 1:2 Minute Volume ( TV X RR ) usually 6-8 L/min SIGH setting – usually 1.5 times the TV ..and range from 1-3 / hr … if applicable Tubing. Water in the tubing – disconnection or kinking of the tubing Humidification ( Humidifier filled with water) and temperature Alarms ( Functioning properly) PEEP and/or Pressure support level , if applicable PEEP is usually 5-15 cm of H2O Observe for Complications 16

17. BUCKING the Ventilator Patient struggles out of phase of ventilator Patient try to breathe out during the ventilators inspiratory phase , or when there is a jerky and abd . muscle effort Causes: Anxiety, hypoxia, increased secretions hypercarbia , inadequate minute volume , pulm edema……………. 17

18. Bucking the ventilator … contd Correct these problems before giving paralyzing agents …..otherwise the underlying problem will mask the condition and condition become worse Muscle relaxants, tranquilizers, analgesics and paralyzing agents are administered – to increase Patient – machine synchrony Obtain Baseline ABG – To monitor progress of therapy 18

19. ALARMS……Causes High pressure alarms Increased secretions in airway Decreased A Way size due to wheezing or bronchospasm Displacement of ET tube Obstructed ET tube – water/kink in tubing Pt coughs gags , or bites the ET tube Anxious pts – fights(Bucking) on Vent LOW Pressure alarm Disconnection /leak in the ventilator or airway cuff Pt stops spontaneous breathing 19

20. COMPLICATIONS Hypotension caused by + ve pressure – which increase intra thoracic pressure and inhibit blood return to heart Air leak Airway obstruction Respiratory complications…. pneumothorax, subcutaneous emphysema due to + ve pressure (Barotrauma ), resp failure G.I alterations – stress ulcers bleeding Malnutrition – if not supported Infections Muscular deconditioning Ventilator dependence or inability to wean 20

21. WEANING ……………. The process of going OFF from ventilator dependence to spontaneous breathing 3 stages ……… pt gradually weaned from ------------ Ventilator Tube Oxygen Decision is made on the physiologic view point by the physician considering his clinical status. It’s a joined effort of Physician – Resp Therapist & Nurse 21

22. Criteria for weaning The ventilator capacities include— Ability to generate Vital Capacity of 10-15 ml/kg ( The minimum required volume is usually range of 1000ml in adult) A spontaneous resp . force at least 20 cmH20 PaO2 > 60mmHg with an FiO2 of < 40% Stable vital signs .. When the above ventilator capacity is adequate CHECK → 22 Baseline Measurements Vital Capacity Insp . Force Resp Rate Resting TV Minute Ventilation ABG levels FiO2

23. Patient Preparation must consider patient as a whole Consider factors that- - impair the deliver the O2 impair elimination of CO2 increase O2 demand ( sepsis, seizures, thyroid imbalance) Decrease in pts over all strength ( Nutrition, Neuro - muscular disease )   Adequate psychological preparations Pt need to know what is expected of them during procedure Explain properly.. Assure the availability of Nurses near him at all time to answer his questions… Often frightened --- reassure that they are improving and well enough to handle his own spontaneous breathing Proper preparation will reduce the weaning time   23

24. Methods of WEANING There is NO BEST method – success depends on – A dequate patient preparation , A vailable equipment, and Interdisciplinary approach to solve problems 24

25. Traditional method : T-Piece trials( one or more) Used with short vent assistance ( <2 days) and pt is awake, alert and breathing without difficulty , good gag reflex, and hemo -dynamically stable Pt breathes spontaneously with humidified O2 During the process pt is maintained on same or higher O2 Conc than when on vent T- Tube ( Brigg’s Adaptor) -- 15 mm connection – Connects O2 source to an artificial airway. ET, tracheostomy. Recommended rate is 10L/min Inspired O2 Conc 24-100% Caution: Clear secretions occlude T-Tube lead to suffocate 25

26. When on T-piece – observe for signs & Symptoms of Hypoxia , increasing fatigue , manifested as: Tachy cardia - PVCs, Ischemic ECC changes Restlessness RR > 35/ mt Use of accessory muscles for breathing Paradoxical chest movement 26

27. If tolerating T –piece trial ………. ABG – 20mts after spont . breathing at a constant FiO2 ( Alveolar-Arterial equalization occur15-20mins ) If ABG↓—exhaustion--- hypoxia- --→ hook back to vent Wean on and off ( Pt who had prolonged vent support need gradual weaning process – even weeks ) Primarily weaned during day time and placed back on Vent during night 27

28. SIMV – Method In pts who – satisfies all criteria for weaning but cannot have spontaneous breathing for long time SIMV for weaning--- observe the following Respiratory Rate Minute Volume Spont /Machine Breaths & TV FiO2 ABG levels No deterioration on parameters--- adequate TV , vent resp gradually decreased-- then weaning is complete Pressure support is used as an adjunct to SIMV weaning – to support insp. pressure ,and boost the spontaneous breaths . PS is reduced gradually as pts strength increases 28

29. Successful weaning is supplemented by intensive pulm care like--- O2 therapy ABG evaluation Pulse oxymetry Bronchodilator therapy Chest physio Adequate Nutrition, hydration, humidification, Incentive spirometry 29

30. Weaning from Tube ET/TT removed only if following criterion met Spontaneous ventilation is adequate Pharyngeal and laryngeal reflexes are active Pt maintain adequate airway and can swallow, move the jaw clench teeth , voluntary cough is effective to bring out secretion Before the tube is removed —a trail with nose/mouth breathing is done – Deflating cuff, using fenestrated tube etc 30

31. Weaning from O2 Pt successfully weaned---- and has adequate respiratory function – weaned from O2 FIO2 is gradually reduced until PO2 is in range of 80-100 mmHg while breathing in Room air If R air PO2 less than 70 supplementary O2 recommended 31

32.   Long tern ventilated pt need aggressive- judicious NUTRITIONAL support as Resp. musculature ( Diaphragm & intercostal muscles ) quickly become weak or atrophied after a few days of Mech. V entilation – especially if nutrition is inadequate , High CHO diet increase CO2—thus increase the work of breathing – 32

33. What you know about OXYGEN supplies & accessories ? 33

34. 34 Central O2 supply Through bulk liquid O2 system which store O2 @-34C (-29F) and deliver it as gas through wall outlets Gas Cylinders Compressed O2 : Non-liquefied gas @ 1800-2400 lbs / Sq inch @ 21C (70 F)

35. 35 40% -- @5-6 L/min 45—50% @ 6-7 L/min 55 –60% @ 7-10L/min Flow rate must be set at least 5L/min to flush the mask. 21--24 % @ 1L/min 24--28 % @ 2L/min 28--32 % @ 3L/ min 32-- 36% @ 4L/min 36 – 40% @ 5L/min 40 – 44% @ 6L/min FiO2 through Nasal Cannula Simple FACE MASK VENTI MASK : Delivers exact O2 Conc. between 20-40% --despite patient’s respiratory pattern

36. Partial Re-Breather Mask 70-90% FiO2 is delivered at 6-15L/min A flow rate high enough to maintain the bag 2/3 rd full during inspiration is needed. Make sure the reservoir bag do not twist or kink – which result in a deflated bag 36

37. GOAL: Patient will be supported on mechanical ventilation without complication- then weaned , extubated . The complications will be detected , treated timely 37

38. Thank you All 38