Mechanical ventilation ppt

Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.

1. NURSING MANAGEMENT OF MECHANICALLY VENTILATED PATIENTS Presented By Bibini Baby 2 nd year MSc . Nsg Govt. College of Nsg Kottayam 1

2. Spontaneous respiration vs. Mechanical ventilation Natural Breathing Negative inspiratory force Air pulled into lungs Mechanical Ventilation Positive inspiratory pressure Air pushed into lungs 2

3. Mechanical ventilation Negative pressure Positive pressure Invasive Noninvasive 3

4. Negative-Pressure Ventilators Early negative-pressure ventilators were known as “ iron lungs. ” The patient ’ s body was encased in an iron cylinder and negative pressure was generated The iron lung are still occasionally used today. 4

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6. Intermittent short-term negative-pressure ventilation is sometimes used in patients with chronic diseases. The use of negative-pressure ventilators is restricted in clinical practice, however, because they limit positioning and movement and they lack adaptability to large or small body torsos (chests) . Our focus will be on the positive-pressure ventilators. 6

7. POSITIVE PRESSURE VENTILATION (INVASIVE) 7

8. Initiation of Mechanical Ventilation Indications Indications for Ventilatory Support Acute Respiratory Failure Prophylactic Ventilatory Support Hyperventilation Therapy 8

9. Initiation of Mechanical Ventilation Indications Acute Respiratory Failure (ARF) Hypoxic lung failure (Type I) Ventilation/perfusion mismatch Diffusion defect Right-to-left shunt Alveolar hypoventilation Decreased inspired oxygen Acute life-threatening or vital organ-threatening tissue hypoxia 9

10. Initiation of Mechanical Ventilation Indications Acute Respiratory Failure (ARF) Acute Hypercapnic Respiratory Failure (Type II) CNS Disorders Reduced Drive To Breathe: depressant drugs, brain or brainstem lesions (stroke, trauma, tumors), hypothyroidism Increased Drive to Breathe: increased metabolic rate ( CO2 production), metabolic acidosis, anxiety associated with dyspnea 10

11. Initiation of Mechanical Ventilation Indications Acute Respiratory Failure (ARF) Acute Hypercapnic Respiratory Failure (Type II) Neuromuscular Disorders Paralytic Disorders: Myasthenia Gravis, Guillain-Barre ´ 11 , poliomyelitis, etc. Paralytic Drugs: Curare, nerve gas, succinylcholine , insecticides Drugs that affect neuromuscular transmission; calcium channel blockers, long-term adenocorticosteroids , etc. Impaired Muscle Function: electrolyte imbalance, malnutrition, chronic pulmonary disease, etc. 11

12. Initiation of Mechanical Ventilation Indications Acute Respiratory Failure (ARF) Acute Hypercapnic Respiratory Failure Increased Work of Breathing Pleural Occupying Lesions: pleural effusions, hemothorax , empyema , pneumothorax Chest Wall Deformities: flail chest, kyphoscoliosis , obesity Increased Airway Resistance: secretions, mucosal edema, bronchoconstriction , foreign body Lung Tissue Involvement: interstitial pulmonary fibrotic diseases 12

13. Initiation of Mechanical Ventilation Indications Acute Respiratory Failure (ARF) Acute Hypercapnic Respiratory Failure Increased Work of Breathing (cont.) Lung Tissue Involvement: interstitial pulmonary fibrotic diseases, aspiration, ARDS, cardiogenic PE, drug induced PE Pulmonary Vascular Problems: pulmonary thromboembolism , pulmonary vascular damage Dynamic Hyperinflation (air trapping) Postoperative Pulmonary Complications 13

14. Initiation of Mechanical Ventilation Prophylactic Ventilatory Support Clinical conditions in which there is a high risk of future respiratory failure Examples: Brain injury, heart muscle injury, major surgery, prolonged shock, smoke injury Ventilatory support is instituted to: Decrease the WOB Minimize O2 consumption and hypoxemia Reduce cardiopulmonary stress Control airway with sedation 14

15. Initiation of Mechanical Ventilation Hyperventilation Therapy Ventilatory support is instituted to control and manipulate PaCO2 to lower than normal levels Acute head injury 15

16. Criteria for institution of ventilatory support: Normal range 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 HO 2 ) 16

17. Criteria for institution of ventilatory support: 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) 17

18. Initiation of Mechanical Ventilation Contraindications Untreated pneumothorax Relative Contraindications Patient’s informed consent Medical futility Reduction or termination of patient pain and suffering 18

19. Essential components in mechanical ventilation Patient Artificial airway Ventilator circuit Mechanical ventilator A/c or D/c power source O2 cylinder or central oxygen supply 19

20. Artificial airways Tracheal intubation Nasal Oral Supraglottic airway   Cricothyrotomy Tracheostomy   20

21. Laryngeal airway 21

22. Intubation Procedure Check and Assemble Equipment: Oxygen flowmeter and O2 tubing Suction apparatus and tubing Suction catheter Ambu bag and mask Laryngoscope with assorted blades 3 sizes of ET tubes Stillet Stethoscope Tape Syringe Sterile gloves

23. Intubation Procedure Position your patient into the sniffing position

24. Intubation Procedure Preoxygenate with 100% oxygen to provide apneic or distressed patient with reserve while attempting to intubate . Do not allow more than 30 seconds to any intubation attempt. If intubation is unsuccessful, ventilate with 100% oxygen for 3-5 minutes before a reattempt.

25. Intubation Procedure Insert Laryngoscope

26. Intubation Procedure After displacing the epiglottis insert the ETT. The depth of the tube for a male patient on average is 21-23 cm at teeth The depth of the tube on average for a female patient is 19-21 at teeth.

27. Intubation Procedure Confirm tube position: By auscultation of the chest Bilateral chest rise Tube location at teeth CO 2 detector – (esophageal detection device or by capnography )

28. Intubation Procedure Stabilize the ETT

29. Ventilator circuit Breathing System Plain Breathing System with Single Water Trap Breathing System with Double Water Trap. Breathing Filters HME Filter Flexible Catheter Mount 29

30. 30 Ventilator circuit Breathing system plain

31. 31 Ventilator Breathing System (1.6m) 

32. 32 Ventilator Breathing System (1.6m)

33. heat & moisture exchanger HME filter 33

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35. MECHANICAL VENTILATOR A mechanical ventilator is a machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilation. 35

36. Types of Mechanical ventilators Transport ventilators   Intensive-care ventilators Neonatal ventilators   Positive airway pressure ventilators for NIV 36

37. Classification of positive-pressure ventilators Ventilators are classified according to how the inspiratory phase ends. The factor which terminates the inspiratory cycle reflects the machine type. They are classified as: 1- Pressure cycled ventilator 2- Volume cycled ventilator 3- Time cycled ventilator 37

38. 1- Volume-cycled ventilator Inspiration is terminated after a preset tidal volume has been delivered by the ventilator. The ventilator delivers a preset tidal volume (VT), and inspiration stops when the preset tidal volume is achieved. 38

39. 2- Pressure-cycled ventilator In which inspiration is terminated when a specific airway pressure has been reached. The ventilator delivers a preset pressure; once this pressure is achieved, end inspiration occurs. 39

40. 3- Time-cycled ventilator In which inspiration is terminated when a preset inspiratory time, has elapsed. Time cycled machines are not used in adult critical care settings. They are used in pediatric intensive care areas. 40

41. Mechanical Ventilators Different Types of Ventilators Available: Will depend on your place of employment Ventilators in use in MCH Servo S by Maquet Savina by Drager

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44. MODES OF VENTILATION

45. Ventilator mode The way the machine ventilates the patient How much the patient will participate in his own ventilatory pattern. Each mode is different in determining how much work of breathing the patient has to do. 45

46. A- Volume Modes 1. CMV or CV 2. AMV or AV 3. IMV 4. SIMV 46

47. B- Pressure Modes 1- Pressure-controlled ventilation (PCV) 2- Pressure-support ventilation (PSV) 3- Continuous positive airway pressure (CPAP) 4- Positive end expiratory pressure (PEEP) 5- Noninvasive bilevel positive airway pressure ventilation (BiPAP) 47

48. Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. The patient CANNOT generate spontaneous breaths, volumes, or flow rates in this mode.

49. Control Mode

50. Assist/Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. The patient CANNOT generate spontaneous volumes, or flow rates in this mode. Each patient generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.

51. Assist Control Volume or Pressure control mode Parameters to set: Volume or pressure Rate I – time FiO2 51

52. Assist Control Machine breaths: Delivers the set volume or pressure Patient’s spontaneous breath: Ventilator delivers full set volume or pressure & I-time Mode of ventilation provides the most support 52

53. Negative deflection, triggering assisted breath Assist Control

54. Delivers a pre-set number of breaths at a set volume and flow rate. Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths. Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking SYCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV):

55. SIMV Synchronized intermittent mandatory ventilation Machine breaths: Delivers the set volume or pressure Patient’s spontaneous breath: Set pressure support delivered Mode of ventilation provides moderate amount of support Works well as weaning mode 55

56. SIMV cont. 56 Machine Breaths Spontaneous Breaths

57. IMV 57 Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical Care

58. 58 Volume Modes

59. PRESSURE REGULATED VOLUME CONTROL (PRVC): This is a volume targeted, pressure limited mode. (available in SIMV or AC) Each breath is delivered at a set volume with a variable flow rate and an absolute pressure limit. The vent delivers this pre-set volume at the LOWEST required peak pressure and adjust with each breath. 59

60. PRVC (Pressure regulated volume control) A control mode, which delivers a set tidal volume with each breath at the lowest possible peak pressure. Delivers the breath with a decelerating flow pattern that is thought to be less injurious to the lung…… “the guided hand”. 60

61. PRCV: Advantages Decelerating inspiratory flow pattern Pressure automatically adjusted for changes in compliance and resistance within a set range Tidal volume guaranteed Limits volutrauma Prevents hypoventilation 61

62. PRVC: Disadvantages Pressure delivered is dependent on tidal volume achieved on last breath Intermittent patient effort  variable tidal volumes Pressure Flow Volume Set tidal volume © Charles Gomersall 2003 62

63. Pressure Flow Volume Set tidal volume PRVC: Disadvantages Pressure delivered is dependent on tidal volume achieved on last breath Intermittent patient effort  variable tidal volumes © Charles Gomersall 2003 63

64. PRVC 64

65. POSITIVE END EXPIRATORY PRESSURE (PEEP): This is NOT a specific mode, but is rather an adjunct to any of the vent modes. PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase. Utilized to keep otherwise collapsing lung units open while hopefully also improving oxygenation. Usually , 5-10 cmH2O 65

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67. Pplat Measured by occluding the ventilator 3-5 sec at the end of inspiration Should not exceed 30 cmH2O 67

68. Peak Pressure (Ppeak) Ppeak = Pplat + Pres Where Pres reflects the resistive element of the respiratory system (ET tube and airway) 68

69. Ppeak Pressure measured at the end of inspiration Should not exceed 50cmH2O? 69

70. Auto-PEEP or Intrinsic PEEP Normally , at end expiration, the lung volume is equal to the FRC When PEEPi occurs , the lung volume at end expiration is greater than the FRC 70

71. Auto-PEEP or Intrinsic PEEP Why does hyperinflation occur ? Airflow limitation because of dynamic collapse No time to expire all the lung volume ( high RR or Vt ) Decreased Expiratory muscle activity Lesions that increase expiratory resistance 71

72. Auto-PEEP or Intrinsic PEEP Adverse effects: Predisposes to barotrauma Predisposes hemodynamic compromises Diminishes the efficiency of the force generated by respiratory muscles Augments the work of breathing Augments the effort to trigger the ventilator 72

73. This is a mode and simply means that a pre-set pressure is present in the circuit and lungs throughout both the inspiratory and expiratory phases of the breath. CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less WOB. The CPAP mode is very commonly used as a mode to evaluate the patients readiness for extubation . 73 Continuous Positive Airway Pressure (CPAP):

74. Combination “Dual Control” Modes Combination or “dual control” modes combine features of pressure and volume targeting to accomplish ventilatory objectives which might remain unmet by either used independently. Combination modes are pressure targeted Partial support is generally provided by pressure support Full support is provided by Pressure Control 74

75. Combination “Dual Control” Modes Volume Assured Pressure Support ( Pressure Augmentation) Volume Support ( Variable Pressure Support) Pressure Regulated Volume Control ( Variable Pressure Control, or Autoflow ) Airway Pressure Release ( Bi-Level, Bi-PAP) 75

76. Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to, or longer than, expiratory time (1:1 to 4:1). Inverse I:E ratios are used in conjunction with pressure control to improve oxygenation by expanding stiff alveoli by using longer distending times, thereby providing more opportunity for gas exchange and preventing alveolar collapse. 76

77. As expiratory time is decreased, one must monitor for the development of hyperinflation or auto-PEEP. Regional alveolar overdistension and barotrauma may occur owing to excessive total PEEP. When the PCV mode is used, the mean airway and intrathoracic pressures rise, potentially resulting in a decrease in cardiac output and oxygen delivery. Therefore, the patient ’ s hemodynamic status must be monitored closely. Used to limit plateau pressures that can cause barotrauma & Severe ARDS 77

78. HIGH FREQUENCY OSCILLATORY VENTILATION

79. HIFI - Theory Resonant frequency phenomena: Lungs have a natural resonant frequency Outside force used to overcome airway resistance Use of high velocity inspiratory gas flow: reduction of effective dead space Increased bulk flow: secondary to active expiration 79

80. HIFI - Advantages Advantages: Decreased barotrauma / volutrauma : reduced swings in pressure and volume Improve V/Q matching: secondary to different flow delivery characteristics Disadvantages: Greater potential of air trapping Hemodynamic compromise Physical airway damage: necrotizing tracheobronchitis Difficult to suction Often require paralysis 80

81. HIFI – Clinical Application Adjustable Parameters Mean Airway Pressure: usually set 2-4 higher than MAP on conventional ventilator Amplitude: monitor chest rise Hertz: number of cycles per second FiO2 I-time: usually set at 33% 81

82. Comparison of HFOV & Conventional Ventilation Differences CMV HFOV Rates 0 - 150 180 - 900 Tidal Volume 4 - 20 ml/kg 0.1 - 3 ml/kg Alveolar Press 0 - > 50 cmH2O 0.1 - 5 cmH2O End Exp Volume Low Normalized Gas Flow Low High 82

83. Video on HFOV http://youtube.com/watch?v=jLroOPoPlig 83

84. INITIAL SETTINGS 84 Select your mode of ventilation Set sensitivity at Flow trigger mode Set Tidal Volume Set Rate Set Inspiratory Flow (if necessary) Set PEEP Set Pressure Limit Inspiratory time Fraction of inspired oxygen

85. Trigger There are two ways to initiate a ventilator-delivered breath: pressure triggering or flow-by triggering When pressure triggering is used, a ventilator-delivered breath is initiated if the demand valve senses a negative airway pressure deflection (generated by the patient trying to initiate a breath) greater than the trigger sensitivity. When flow-by triggering is used, a continuous flow of gas through the ventilator circuit is monitored. A ventilator-delivered breath is initiated when the return flow is less than the delivered flow, a consequence of the patient's effort to initiate a breath 85

86. Post Initial Settings 86 Obtain an ABG (arterial blood gas) about 30 minutes after you set your patient up on the ventilator. An ABG will give you information about any changes that may need to be made to keep the patient’s oxygenation and ventilation status within a physiological range.

87. ABG 87 Goal: Keep patient’s acid/base balance within normal range: pH 7.35 – 7.45 PCO 2 35-45 mmHg PO2 80-100 mmHg

88. Initiation of Mechanical Ventilation Initial Ventilator Settings Tidal Volume Spontaneous VT for an adult is 5 – 7 ml/kg of IBW Determining VT for Ventilated Patients A range of 6 – 12 ml/kg IBW is used for adults 10 – 12 ml/kg IBW (normal lung function) 8 – 10 ml/kg IBW (obstructive lung disease) 6 – 8 ml/kg IBW (ARDS) – can be as low as 4 ml/kg A range of 5 – 10 ml/kg IBW is used for infants and children 88

89. Initiation of Mechanical Ventilation Initial Ventilator Settings Respiratory Rate Normal respiratory rate is 12-18 breaths/min. A range of 8 – 12 breaths per minute (BPM) Rates should be adjusted to try and minimize auto-PEEP 89

90. Initiation of Mechanical Ventilation Initial Ventilator Settings Minute Ventilation Respiratory rate is chosen in conjunction with tidal volume to provide an acceptable minute ventilation = VT x f Normal minute ventilation is 5-10 L/min Estimated by using 100 mL /kg IBW ABG needed to assess effectiveness of initial settings If PaCO2 >45 ( minute ventilation via f or VT) If PaCO2 <35 ( minute ventilation via f or VT) 90

91. Initiation of Mechanical Ventilation Initial Ventilator Settings Inspiratory Flow Rate of Gas Flow As a beginning point , flow is normal set to deliver inspiration in about 1 second (range 0.8 to 1.2 sec.), producing an I:E ratio of approximately 1:2 or less (usually about 1:4) This can be achieved with an initial peak flow of about 60 L/min (range of 40 to 80 L/min) Most importantly, flows are set to meet a patient’s inspiratory demand 91

92. Expiratory Flow Pattern 92 Inspiration Expiration Time (sec) Flow (L/min) Beginning of expiration exhalation valve opens Peak Expiratory Flow Rate PEFR Duration of expiratory flow Expiratory time T E

93. Initiation of Mechanical Ventilation Flow Patterns Selection of flow pattern and flow rate may depend on the patient’s lung condition, e.g., Post – operative patient recovering from anesthesia may have very modest flow demands Young adult with pneumonia and a strong hypoxemic drive would have very strong flow demands Normal lungs: Not of key importance 93

94. Initiation of Mechanical Ventilation Initial Ventilator Settings Flow Pattern Constant Flow (rectangular or square waveform) Generally provides the shortest TI Some clinician choose to use a constant (square) flow pattern initially because it enables them to obtain baseline measurements of lung compliance and airway resistance 94

95. Initiation of Mechanical Ventilation Flow Pattern Sine Flow May contribute to a more even distribution of gas in the lungs Peak pressures and mean airway pressure are about the same for sine and square wave patterns 95

96. Initiation of Mechanical Ventilation Initial Ventilator Settings Flow Pattern Descending (decelerating) Ramp Improves distribution of ventilation, results in a longer TI, decreased peak pressure, and increased mean airway pressure (which increases oxygenation) 96

97. Initiation of Mechanical Ventilation Initial Ventilator Settings Positive End Expiratory Pressure (PEEP) Initially set at 3 – 5 cm H2O Restores FRC and physiological PEEP that existed prior to intubation Subsequent changes are based on ABG results Useful to treat refractory hypoxemia Contraindications for therapeutic PEEP (>5 cm H2O) Hypotension Elevated ICP Uncontrolled pneumothorax 97

98. Initiation of Mechanical Ventilation Initial Ventilator Settings FiO2 Initially 100% Severe hypoxemia Abnormal cardiopulmonary functions Post-resuscitation Smoke inhalation ARDS After stabilization, attempt to keep FiO2 <50% Avoids oxygen-induced lung injuries Absorption atelectasis Oxygen toxicity 98

99. Initiation of Mechanical Ventilation FiO2 of 40% or Same FiO2 prior to mechanical ventilation Patients with mild hypoxemia or normal cardiopulmonary function Drug overdose Uncomplicated postoperative recovery 99

100. Initiation of Mechanical Ventilation Initial Ventilator Settings For PCV Rate, T I , and I:E ratio are set in PCV as they are in Volume mode The pressure gradient (PIP-PEEP) is adjusted to establish volume delivery Remember: Volume delivery changes as lung characteristics change and can vary breath to breath 100

101. Initiation of Mechanical Ventilation Initial Ventilator Settings For PCV Flow Pattern PCV provides a descending ramp waveform Note: The patient can vary the inspiratory flow on demand 101

102. Initiation of Mechanical Ventilation Initial Ventilator Settings For PCV Rise Time (slope, flow acceleration) Rise time is the amount of T I it takes for the ventilator to reach the set pressure at the beginning of inspiration Inspiratory flow delivery during PCV can be adjusted with an inspiratory rise time control Ventilator graphics can be used to set the rise time 102

103. ● Sigh A deep breath. A breath that has a greater volume than the tidal volume. It provides hyperinflation and prevents atelectasis . Sigh volume : ------------------Usual volume is 1.5 – 2 times tidal volume. Sigh rate/ frequency : ---------Usual rate is 4 to 8 times per hour. 103

104. Ensuring humidification and thermoregulation All air delivered by the ventilator passes through the water in the humidifier, where it is warmed and saturated or through an HME filter Humidifier temperatures should be kept close to body temperature 35 º C- 37 º C. In some rare instances (severe hypothermia), the air temperatures can be increased. The humidifier should be checked for adequate water levels 104

105. Initiation of Mechanical Ventilation Ventilator Alarm Settings High Minute Ventilation Set at 2 L/min or 10%-15% above baseline minute ventilation Patient is becoming tachypneic (respiratory distress) High Respiratory Rate Alarm Set 10 – 15 BPM over observed respiratory rate Patient is becoming tachypneic (respiratory distress) 105

106. Initiation of Mechanical Ventilation Ventilator Alarm Settings Low Exhaled Tidal Volume Alarm Set 100 ml or 10%-15% lower than expired mechanical tidal volume Causes System leak Circuit disconnection ET Tube cuff leak 106

107. Initiation of Mechanical Ventilation Ventilator Alarm Settings High Inspiratory Pressure Alarm Set 10 – 15 cm H2O above PIP Common causes: Water in circuit Kinking or biting of ET Tube Secretions in the airway Bronchospasm Tension pneumothorax Decrease in lung compliance Increase in airway resistance Coughing 107

108. Initiation of Mechanical Ventilation Ventilator Alarm Settings Low Inspiratory Pressure Alarm Set 10 – 15 cm H2O below observed PIP Causes System leak Circuit disconnection ET Tube cuff leak High/Low PEEP/CPAP Alarm (baseline alarm) High: Set 3-5 cm H2O above PEEP Circuit or exhalation manifold obstruction Auto – PEEP Low: Set 2-5 cm H2O below PEEP Circuit disconnect 108

109. Initiation of Mechanical Ventilation Ventilator Alarm Settings High/Low FiO2 Alarm High: 5% over the analyzed FiO2 Low: 5% below the analyzed FiO2 High/Low Temperature Alarm Heated humidification High: No higher than 37  C Low: No lower than 30 C 109

110. Initiation of Mechanical Ventilation Ventilator Alarm Settings Apnea Alarm Set with a 15 – 20 second time delay In some ventilators, this triggers an apnea ventilation mode Apnea Ventilation Settings Provide full ventilatory support if the patient become apneic VT 8 – 12 mL /kg ideal body weight Rate 10 – 12 breaths/min FiO2 100% 110

111. TROUBLESHOOTING 111

112. Trouble Shooting the Vent Common problems High peak pressures Patient with COPD Ventilator asynchrony ARDS 112

113. Trouble Shooting the Vent If peak pressures are increasing: Check plateau pressures by allowing for an inspiratory pause (this gives you the pressure in the lung itself without the addition of resistance) If peak pressures are high and plateau pressures are low then you have an obstruction If both peak pressures and plateau pressures are high then you have a lung compliance issue 113

114. Trouble Shooting the Vent High peak pressure differential: 114 High Peak Pressures Low Plateau Pressures High Peak Pressures High Plateau Pressures Mucus Plug ARDS Bronchospasm Pulmonary Edema ET tube blockage Pneumothorax Biting ET tube migration to a single bronchus Effusion

115. COPD If you have a patient with history of COPD/asthma with worsening oxygen saturation and increasing hypercapnia differential includes: Must be concern with breath stacking or auto- PEEP Low VT with increased exhalation time is advisable Baseline ABGs reflect an elevated PaCO 2 should not hyperventilated. Instead, the goal should be restoration of the baseline PaCO 2 . These patients usually have a large carbonic acid load, and lowering their carbon dioxide levels rapidly may result in seizures. 115

116. COPD and Asthma Goals: Diminish dynamic hyperinflation Diminish work of breathing Controlled hypoventilation (permissive hypercapnia) 116

117. Trouble Shooting the Vent Increase in patient agitation and dis-synchrony on the ventilator: Could be secondary to overall discomfort Increase sedation Could be secondary to feelings of air hunger Options include increasing tidal volume, increasing flow rate, adjusting I:E ratio, increasing sedation 117

118. Trouble shooting the vent If you are concern for acute respiratory distress syndrome (ARDS) Correlate clinically with radiologic findings of diffuse patchy infiltrate on CXR Obtain a PaO2/FiO2 ratio (if < 200 likely ARDS) Begin ARDSnet protocol: Low tidal volumes Increase PEEP rather than FiO2 Consider increasing sedation to promote synchrony with ventilator 118

119. Accidental Extubation Role of the Nurse : Ensure the Ambu bag is attached to the oxygen flowmeter and it is on ! Attach the face mask to the Ambu bag and after ensuring a good seal on the patient’s face; supply the patient with ventilation. 119

120. Pulmonary Disease: Obstructive Airway obstruction causing increase resistance to airflow: e.g. asthma Optimize expiratory time by minimizing minute ventilation Bag slowly after intubation Don’t increase ventilator rate for increased CO 2 120

121. Pulmonary Disease: Restrictive Compromised lung volume: Intrinsic lung disease External compression of lung Recruit alveolia, optimize V/Q matching Lung protective strategies High PEEP Pressure limiting PIP: 30-35 cmH2O Low tidal volume: 4-8 ml/kg FiO2 <60% Permissive hypercarbia Permissive hypoxia 121

122. In a patient with head injury , Respiratory alkalosis may be required to promote cerebral vasoconstriction, with a resultant decrease in ICP. In this case, the tidal volume and respiratory rate are increased ( hyperventilation) to achieve the desired alkalotic pH by manipulating the PaCO 2 . 122

123. Complications of Mechanical Ventilation:- I- Airway Complications, II- Mechanical complications, III- Physiological Complications, IV- Artificial Airway Complications. 123

124. I- Airway Complications 1- Aspiration 2- Decreased clearance of secretions 3- Nosocomial or ventilator-acquired pneumonia 124

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126. WHAT IS SUCTIONING?..... The patient with an artificial airway is not capable of effectively coughing, the mobilization of secretions from the trachea must be facilitated by aspiration. This is called as suctioning.

127. Indications Coarse breath sounds Noisy breathing Visible secretions in the airway Decreased SpO 2 in the pulse oximeter & Deterioration of arterial blood gas values Clinically increased work of breathing Changes in monitored flow/pressure graphics Increased PIP; decreased Vt during ventilation

128. NECESSARY EQUIPMENT Vaccum source with adjustable regulator suction jar stethoscope Sterile gloves for open suctioning method Clean gloves for closed suctioning method Sterile catheter Clear protective goggles, apron & mask Sterile normal saline Bain’s circuit or ambu bag for preoxygenate the patient Suction tray with hot water for flushing

129. TYPES OF SUCTIONING OPEN SUCTION CLOSED SUCTION

130. OPEN SUCTION SYSTEM: Regularly using system in the intubated patients . CLOSED SUCTION SYSTEM: This is used to facilitate continuous mechanical ventilation and oxygenation during the suctioning. Closed suctioning is also indicated when PEEP level above 10cmH 2 O.

131. Patient Preparation Explain the procedure to the patient (If patient is concious ). The patient should receive hyper oxygenation by the delivery of 100% oxygen for >30 seconds prior to the suctioning (by increasing the FiO 2 by mechanical ventilator). Position the patient in supine position. Auscultate the breath sounds.

132. PROCEDURE Perform hand hygiene, wash hands. It reduces transmission of microorganisms. Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. For adult a pressure of 100-120 mmHg, 80-100mmhg for children & 60-80mmhg for infants.

133. Goggles, mask & apron should be worn to prevent splash from secretions Preoxygenate with 100% O 2 Open the end of the suction catheter package & connect it to suction tubing (If you are alone) Wear sterile gloves with sterile technique With a help of an assistant open suction catheter package & connect it to suction tubing Continue…..

134. Continue….. With a help of an assistant disconnect the ventilator Kink the suction tube & insert the catheter in to the ETtube until resistance is felt Resistance is felt when the catheter impacts the carina or bronchial mucosa, the suction catheter should be withdrawn 1cm out before applying suction

135. Continue..... Apply continuous suction while rotating the suction catheter during removal The duration of each suctioning should be less the 15sec. Instill 3 to 5ml of sterile normal saline in to the artificial airway, if required Assistant resumes the ventilator Give four to five manual breaths with bag or ventilator

136. Continue….. Continue making suction passes, bagging patient between passes, until clear of secretions, but no more than four passes Return patient to ventilator Flush the catheter with hot water in the suction tray Suction nares & oropharynx above the artificial airway Discard used equipments Flush the suction tube with hot water Auscultate chest Wash hands Document including indications for suctioning & any changes in vitals & patient’s tolerance

137. Closed suctioning procedure Wash hands Wear clean gloves Connect tubing to closed suction port Pre-oxygenate the patient with 100% O 2 Gently insert catheter tip into artificial airway without applying suction, stop if you met resistance or when patient starts coughing and pull back 1cm out

138. Closed suction 138

139. Continue….. Place the dominant thumb over the control vent of the suction port, applying continuous or intermittent suction for no more than 10 sec as you withdraw the catheter into the sterile sleeve of the closed suction device Repeat steps above if needed Clean suction catheter with sterile saline until clear; being careful not to instill solution into the ETtube Suction oropharynx above the artificial airway Wash hands

140. ASSESSMENT OF OUTCOME Improvement in breath sounds. Decreased peak inspiratory pressure; Increased tidal volume delivery during ventilation. Improvement in arterial blood gas values or saturation as reflected by pulse oximetry . (SpO 2 ) Removal of pulmonary secretions.

141. CONTRAINDICATIONS Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. Suctioning is contraindicated when there is fresh bleeding. When indicated, there is no absolute contraindication to endotracheal suctioning because the decision to abstain from suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.

142. LIMITATIONS OF METHOD Suctioning is potentially an harmful procedure if carriedout improperly. Suctioning should be done when clinically necessary (not routinely). The need for suctioning should be assessed at least every 2hrs or more frequently as need arises.

143. http:// www.youtube.com/watch?v=bXXWNCYZ_N0 143

144. LIMITATIONS OF METHOD Suctioning is potentially an harmful procedure if carriedout improperly. Suctioning should be done when clinically necessary (not routinely). The need for suctioning should be assessed at least every 2hrs or more frequently as need arises.

145. II- Mechanical complications 1- Hypoventilation with atelectasis with respiratory acidosis or hypoxemia. 2- Hyperventilation with hypocapnia and respiratory alkalosis 3- Barotrauma a- Closed pneumothorax, b- Tension pneumothorax, c- Pneumomediastinum, d- Subcutaneous emphysema. 4- Alarm “ turned off ” 5- Failure of alarms or ventilator 6- Inadequate nebulization or humidification 7- Overheated inspired air, resulting in hyperthermia 145

146. III- Physiological Complications 1- Fluid overload with humidified air and sodium chloride (NaCl) retention 2- Depressed cardiac function and hypotension 3- Stress ulcers 4- Paralytic ileus 5- Gastric distension 6- Starvation 7- Dyssynchronous breathing pattern 146

147. IV- Artificial Airway Complications A- Complications related to Endotracheal Tube:- 1- Tube kinked or plugged 2- Tracheal stenosis or tracheomalacia 3- Mainstem intubation with contralateral ( located on or affecting the opposite side of the Lung ) lung atelectasis 5- Cuff failure 6- Sinusitis 7- Otitis media 8- Laryngeal edema 147

148. B- Complications related to Tracheostomy tube:- 1- Acute hemorrhage at the site 2- Air embolism 3- Aspiration 4- Tracheal stenosis 5- Failure of the tracheostomy cuff 6- Laryngeal nerve damage 7- Obstruction of tracheostomy tube 8- Pneumothorax 9- Subcutaneous and mediastinal emphysema 10- Swallowing dysfunction 11- Tracheoesophageal fistula 12- Infection 14- Accidental decannulation with loss of airway 148

149. Nursing care of patients on mechanical ventilation Assessment: 1- Assess the patient 2- Assess the artificial airway (tracheostomy or endotracheal tube) 3- Assess the ventilator 149

150. Nursing Interventions 1- Maintain airway patency & oxygenation 2- Promote comfort 3- Maintain fluid & electrolytes balance 4- Maintain nutritional state 5- Maintain urinary & bowel elimination 6- Maintain eye , mouth and cleanliness and integrity:- 7- Maintain mobility/ musculoskeletal function:- 150

151. Nursing Interventions 8- Maintain safety:- 9- Provide psychological support 10- Facilitate communication 11- Provide psychological support & information to family 12- Responding to ventilator alarms / Troublshooting ventilator alarms 13- Prevent nosocomial infection 14- Documentation 151

152. Responding To Alarms If an alarm sounds, respond immediately because the problem could be serious. Assess the patient first , while you silence the alarm. If you can not quickly identify the problem, take the patient off the ventilator and ventilate him with a resuscitation bag connected to oxygen source until the physician arrives. A nurse or respiratory therapist must respond to every ventilator alarm. 152

153. Alarms must never be ignored or disarmed. Ventilator malfunction is a potentially serious problem. Nursing or respiratory therapists perform ventilator checks every 2 to 4 hours, and recurrent alarms may alert the clinician to the possibility of an equipment-related issue. 153

154. When device malfunction is suspected, a second person manually ventilates the patient while the nurse or therapist looks for the cause. If a problem cannot be promptly corrected by ventilator adjustment, a different machine is procured so the ventilator in question can be taken out of service for analysis and repair by technical staff. 154

155. WEANING 155

156. Weaning readiness Criteria Awake and alert Hemodynamically stable, adequately resuscitated, and not requiring vasoactive support Arterial blood gases (ABGs) normalized or at patient ’ s baseline - PaCO 2 acceptable - PH of 7.35 – 7.45 - PaO 2 > 60 mm Hg , - SaO 2 >92% - FIO 2 ≤40% 156

157. Positive end-expiratory pressure (PEEP) ≤5 cm H 2 O F < 25 / minute Vt 5 ml / kg VE 5- 10 L/m (f x Vt ) VC > 10- 15 ml / kg 157

158. Chest x-ray reviewed for correctable factors; treated as indicated, Major electrolytes within normal range, Hematocrit >25%, Core temperature >36°C and <39°C, Adequate management of pain/anxiety/agitation, Adequate analgesia/ sedation (record scores on flow sheet), No residual neuromuscular blockade. 158

159. 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. 159

160. 1- T-Piece trial It consists of removing the patient from the ventilator and having him / her breathe spontaneously on a T-tube connected to oxygen source. During T-piece weaning, periods of ventilator support are alternated with spontaneous breathing. The goal is to progressively increase the time spent off the ventilator. 160

161. 2-Synchronized Intermittent Mandatory Ventilation ( SIMV) Weaning SIMV is the most common method of weaning. It consists of gradually decreasing the number of breaths delivered by the ventilator to allow the patient to increase number of spontaneous breaths 161

162. 3-Continuous Positive Airway Pressure ( CPAP) Weaning When placed on CPAP, the patient does all the work of breathing without the aid of a back up rate or tidal volume. No mandatory (ventilator-initiated) breaths are delivered in this mode i.e. all ventilation is spontaneously initiated by the patient. Weaning by gradual decrease in pressure value 162

163. 4- Pressure Support Ventilation (PSV) Weaning The patient must initiate all pressure support breaths. During weaning using the PSV mode the level of pressure support is gradually decreased based on the patient maintaining an adequate tidal volume (8 to 12 mL/kg) and a respiratory rate of less than 25 breaths/minute. PSV weaning is indicated for :- - Difficult to wean patients - Small spontaneous tidal volume. 163

164. Role of nurse before weaning:- 1- Ensure that indications for the implementation of Mechanical ventilation have improved 2- Ensure that all factors that may interfere with successful weaning are corrected:- - Acid-base abnormalities - Fluid imbalance - Electrolyte abnormalities - Infection - Fever - Anemia - Hyperglycemia - Sleep deprivation 164

165. Role of nurse before weaning:- 3- Assess readiness for weaning 4- Ensure that the weaning criteria / parameters are met. 5- Explain the process of weaning to the patient and offer reassurance to the patient. 6- Initiate weaning in the morning when the patient is rested. 7- Elevate the head of the bed & Place the patient upright 8- Ensure a patent airway and suction if necessary before a weaning trial, 165

166. Role of nurse before weaning:- 9 - Provide for rest period on ventilator for 15 – 20 minutes after suctioning. 10- Ensure patient ’ s comfort & administer pharmacological agents for comfort, such as bronchodilators or sedatives as indicated. 11- Help the patient through some of the discomfort and apprehension. 13- Evaluate and document the patient ’ s response to weaning. 166

167. Role of nurse during weaning:- 1- Wean only during the day. 2- Remain with the patient during initiation of weaning. 3- Instruct the patient to relax and breathe normally. 4- Monitor the respiratory rate, vital signs, ABGs, diaphoresis and use of accessory muscles frequently. If signs of fatigue or respiratory distress develop. Discontinue weaning trials. 167

168. Signs of Weaning Intolerance Criteria Diaphoresis Dyspnea & 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 > 110b/m,Sustained heart rate >20% higher or lower than baseline 168

169. Signs of Weaning Intolerance 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 SaO2 < 90%, PaO2 < 60 mmHg, decrease in PH of < 7.35. Increase in PaCO 2 169

170. Role of nurse after weaning 1- Ensure that extubation criteria are met . 2- Decanulate or extubate 2- Documentation 170

171. Noninvasive Bilateral Positive Airway Pressure Ventilation ( BiPAP ) BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or nasal prongs, or a full-face mask. The system allows the clinician to select two levels of positive-pressure support : An inspiratory pressure support level (referred to as IPAP) An expiratory pressure called EPAP (PEEP/CPAP level). 171

172. NON INVASIVE VENTILATION 172

173. Absolute contraindications Coma Cardiac arrest Respiratory arrest Any condition requiring immediate intubation 173

174. Suitable clinical conditions Chronic obstructive pulmonary disease Cardiogenic pulmonary edema After discontinuation of  mechanical ventilation  (COPD) OSP 174

175. Patient interfaces full face masks , nasal pillows, Nasal masks and orofacial masks 175

176. Ventilators Usual ventilators for invasive ventilation Special noninvasive ventilators Modes of ventilation CPAP BiPAP 176

177. Top 10 care essentials for ventilator patients Review communications . Check ventilator settings and modes. Suction appropriately. Assess pain and sedation needs. Prevent infection. 177

178. Top 10 care essentials for ventilator patients Prevent hemodynamic instability. Manage the airway. Meet the patient’s nutritional needs. Wean the patient from the ventilator appropriately. Educate the patient and family. 178

179. 179 THANK YOU