Mechanical Ventilator by AJ

i have prepared this ppt. from various Books as a refrences as well as uses of web pages and explain and modify in simplify language which are easily understand by medical or para medical personnel..thank you..

1. Basics of Mechanical Ventilation Joshi Abhishek Ashvinbhai S.Y.P.B.B.Sc.Nursing Gov.College of Nursing Jamnagar

2. Definition & Introduction of Mechanical Ventilation Goals Purposes Indication of Mechanical Ventilation Essential Terminologies Types of Mechanical Ventilation/Ventilator Ventilator Alarms Complications of Ventilation Weaning Nursing Care of Ventilated Clients Content

3. THOUGHT OF THE DAY YESTERDAY’S A PAST… …..TOMORROW IS A FUTURE…. …. BUT…. TODAY IS A GIFT ...THAT’S WHY IT’S CALLED PRESENT….!

4. “Mechanical ventilation is the use of a ventilator to move room air or oxygen enriched air into and out of the lungs mechanically to maintain proper levels of oxygen and carbon dioxide in the blood.” Definitio n

5. Mechanical ventilation alone does not treat or reverse the underlying pathology leading to the need for ventilator support. Rather, it is applied as one of the support systems until the reversal of the pathological condition, so that the patient may then become weaned from mechanical ventilation. Goals of Mechanical Ventilation

6. Cont… GOAL Improve gas exchange Relive respiratory distress Improve pulmonary mechanics Permit lung and airway healing Avoid complication TARGET Reverse hypoxemia/Relieve acute respiratory acidosis Reverse respiratory muscle fatigue Prevent and reverse atelectasis Improve lung compliance/Maintain lung and airway function Prevent disuse respiratory muscle dystrophy

7. To maintain gas exchange in case of acute and chronic respiratory failure. To maintain ventilator support after CPR. To reduce pulmonary vascular resistance. To excrete increased CO2 production. To give general anesthesia with muscle relaxants . Purposes

8. Acute respiratory failure Apnea or impending inability to breath Severe H ypoxia/Hypoxemia Respiratory muscle fatigue Cardiac Insufficiency Neurological problems Therapeutic and prophylactic Indications

9. Respiratory failure: An inability of the heart and lungs to provide adequate tissue oxygenation or removal of carbon dioxide. Hypoxemic respiratory failure – lung failure Hypercapnic respiratory failure – pump failure Neuromuscular diseases : Myasthenia Gravis, Guillain-Barre Syndrome , and Poliomyelitis (failure of the normal respiratory neuromuscular system) Musculoskeletal abnormalities : Such as chest wall trauma . Infectious diseases of the lung such as pneumonia, tuberculosis . Cont…

10. Obstructive lung disease in the form of asthma , chronic bronchitis or emphysema . Conditions such as pulmonary edema, atelectasis , pulmonary fibrosis . Patients who has received general anesthesia as well as post cardiac arrest patients requires ventilatory support until they have recovered from the effects of the anesthesia or out from a Danger. Cont…

11. Cont… Normal range Ventilation indicated Parameters 15-20 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 )

12. Cont… 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)

13. Shall we learn some basic Terminologies about Mechanical Ventilator?

14. Independent variables : “ The parameters that are set by clinician.” Dependent variables : “ The parameters measured by the ventilators.” Fraction of inspired oxygen ( FiO2): “The concentration of O2 in the inspired gas, usually between 21% and 100% O2. The lowest possible fraction of inspired oxygen (FiO2) necessary to meet oxygenation goals should be used. “ Essential Terminologies

15. Tidal volume (TV): “The amount of air delivered to the patient per breath. It is expressed in milliliters.” A starting point for the VT setting is 8 to 10ml/kg of ideal weight. Respiratory rate/frequency ( f): “ The number of breaths per minute. This can be from the ventilator, the patient, or both . “ The RR is set as near to physiological rates (14 to 20 breaths/min) as possible. Cont…

16. Minute ventilation (V E): “ The product of V and respiratory frequency (VT * f). It is usually expressed in liters/minute .” Exhaled Tidal Volume:(E TV): “ It is the amount of gas that comes out of the patients lungs on exhalation .” This is the most accurate measure of the volume received by the patient If the ETV deviates from the set TV by 50ml or more, troubleshoot the system to identify the source of gas loss. Cont…

17. Inspiratory to Expiratory ratio (I:E): “ The I:E ratio is usually set to mimic the pattern of spontaneous ventilation .” During spontaneous breathing, the normal I:E ratio is 1:2, 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. Depending on the disease process, such as in ARDS, the I:E ratio can be changed to improve ventilation. Cont…

18. Inverse Inspiratory to Expiratory ratio: “I:E ratios such as 1:1,2:1 and 3:1 are called inverse I:E ratios” Inverse I:E ratio allows unstable alveoli time to fill and also prevents collapse by shortened expiratory phase . 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. Cont…

19. Positive end-expiratory pressure ( PEEP): “ The amount of positive pressure that is maintained at end-expiration .” Typical settings for PEEP are 5 to 20 cm H2O PEEP increases oxygenation by preventing collapse of small airways It increases the functional residual capacity of the lungs A typical initial applied PEEP is 5 cmH2O. However, up to 20 cmH2O may be used in patients undergoing low tidal volume ventilation for acute respiratory distress syndrome (ARDS) Cont…

20. Auto PEEP: “ Auto PEEP is the spontaneous development of PEEP caused by gas trapping in the lung resulting from insufficient expiratory time and incomplete exhalation.” Causes of auto PEEP formation include rapid RR, high VE demand, airflow obstruction and inverse I:E ratio ventilation . Auto PEEP = Total PEEP - Set PEEP Cont…

21. Sensitivity ( Trigger Sensitivity) : “ The sensitivity function controls the amount of patient effort needed to initiate an inspiration.” Increasing the sensitivity (requiring less negative force) decreases the amount of work the patient must do to initiate a ventilator breath. Decreasing the sensitivity increases the amount of negative pressure that the patient needs to initiate inspiration and increases the work of breathing . The most common setting for pressure sensitivity are -1 to -2 cm H 2 O The more negative the number the harder it to breath. Cont…

22. Peak airway pressure (Paw): “ The pressure that is required to deliver the TV to the patient . It has a unit of centimeters of water (cm H2O ).” Plateau pressure ( Pplat ): “ The pressure that is needed to distend the lung. This pressure can only be obtained by applying an end inspiratory pause . It also has a unit of cm H2O.” Cont…

23. Peak inspiratory Pressure (PIP): In adults if the peak airway pressure is persistently above 45 cmH 2 O, the risk of barotrauma is increased and efforts should be made to try to reduce the peak airway pressure. “Increasing PIP is also sign of Blockage of airway and needed to suctioning or change Et /TT.” Cont…

24. Mean airway pressure: “ The time-weighted average pressure during the respiratory cycle . It is expressed in cm H2O.” Cont…

25. (i) Invasive ventilation or conventional mechanical ventilation (MV) & (ii) non invasive ventilation (NIV). OR (i) Positive Pressure Ventilation & (ii) N egative pressure ventilation. Types of Ventilation

26. Non Invasive Ventilation: “ Ventilatory support that is given without establishing endo-tracheal intubation or tracheostomy is called Non invasive mechanical ventilation.” Invasive Ventilation: “Ventilatory support that is given through endotracheal intubation or tracheostomy is called as Invasive mechanical ventilation.” Definition

27. (i) Non Invasive Ventilation Negative pressure: Producing Neg. pressure intermittently in the pleural space / around the thoracic cage. e.g.: Iron Lung Positive pressure: Delivering air/gas with positive pressure to the airway. e.g.: BIPAP & CPAP ( O2 mask , Nasal cannula etc.

28. Elongated tank, which encases the patient up to the neck . The neck is sealed with a rubber gasket, the patient's face are exposed to the room air. These exert negative pressure on the external chest decreasing the intra-thoracic pressure during inspiration , allows air to flow into the lungs, filling its volume. The cessation of the negative pressure causes the chest wall to fall and exhalation to occur. (i) Negative Pressure Ventilation

29. Iron Lung

30. The patient ’ s body was encased in an iron cylinder and negative pressure was generated The iron lung are still occasionally used today . These are simple to use and do not require intubations of the airway; consequently, they are especially adaptable for home use. It is used mainly in chronic respiratory failure associated with neuromuscular conditions such as poliomyelitis, muscular dystrophy and myasthenia gravis. Cont…

31. 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). Cont…

32. Positive pressure ventilation inflate the lungs by exerting positive pressure on the airway forcing the alveoli to expand during inspiration. Expiration occurs passively . Positive-pressure ventilators require an artificial airway (Endotracheal or tracheostomy tube) in invasive ventilation and in NIV includes BiPAP Mask , O2 mask , Nasal mask/cannula , O2 high concentrated reservoir mask etc. Inspiration can be triggered either by the patient or the machine. (ii) Positive Pressure Ventilation

33. BiPAP Mask ( NIV )

34. CPAP Nasal Mask

35. Invasive mechanical ventilation is implemented once a cuffed tube is inserted into the trachea to allow conditioned gas ( warmed, oxygenated , and humidified) to be delivered to the airways and lungs at pressures above atmospheric pressure . Ventilatory support that is given through endotracheal intubation or tracheostomy is called as Invasive mechanical ventilation Invasive Ventilation

36. Positive invasive pressure ventilation deliver gas to the patient under positive-pressure, during the inspiratory phase. Cont…

37. A/C: Assist-Control Ventilation V/C: Volume-Control Ventilation T/C: Time-Control Ventilation IMV : Intermittent Mandatory Ventilation SIMV : Synchronized Intermittent Mandatory Ventilation BiPAP ( Bi-level/Biphasic ): Non- invesive Pressure Ventilation with Pressure Support (consists of 2 levels of pressure ) PRVC: Pressure Regulated Volume Control Ventilator Setting Terminology

38. CPAP : Continuous Positive Airway Pressure PSV : Pressure Support Ventilation NIPPV : Non-Invasive Positive Pressure Ventilation PIP : Peak Inspiratory Pressure FiO2 : Fraction of inspiratory O2 PEEP: Peak End Expiratory Pressure Cont…

39. Modes of mechanical ventilation are the techniques that the ventilator and patient work together to perform the respiratory cycle. ( 1 ) Pressure Cycled M odes ( 2 ) Volume Cycled Modes ( 3 ) Time Cycled Modes Modes of Ventilation

40. Pressure- Controlled Ventilation (i) Continuous Positive Airway Pressure(CPAP) (ii) Bi-Level (Bi-Phasic) positive airway- pressure (BiPAP) (iii) Pressure Support Ventilation (PSV) (iv) Pressure Assist/ Control Ventilation (PCV) (v)Pressure- Controlled Inverse Ratio-Ventilation (1) Pressure Cycled Ventilation

41. CPAP is positive pressure applied throughout the respiratory cycle to the spontaneously breathing patient . A continuous level of elevated pressure is provided through the patient circuit to maintain adequate oxygenation , decrease the work of breathing. CPAP may be used invasively through an endotracheal tube or tracheostomy or noninvasively with a face mask or nasal prongs. (i) CPAP (Continuous Positive Airway Pressure)

42. provides pressure at end expiration, which prevents alveolar collapse and improves the functional residual capacity and oxygenation. CPAP allows the nurse to observe the ability of the patient to breath spontaneously while still on the ventilator . It may used as a Weaning Mode. Cont…

43. The ventilator is used to deliver CPAP during weaning the nurse can monitor the adequacy of the patient’s TV. Alarms should be set to detect ETV and apnea. If a patient in this mode can maintain his own respiratory effort without excess work, if the ABG’s are good, and the patient has good respiratory mechanics then extubation is at hand . Nurses Responsibility on CPAP

44. The patient breaths spontaneously while the ventilator applies a pre-determined amount of positive pressure to the airways upon inspiration. Pressure support ventilation augments patient ’ s spontaneous breaths with positive pressure boost during inspiration i.e. assisting each spontaneous inspiration . Helps to overcome airway resistance and reducing the work of breathing. (ii) PSV (Pressure Support Ventilation)

45. Indicated for patients with small spontaneous tidal volume and difficult to wean patients. Patient must initiate all pressure support breaths. Pressure support ventilation may be combined with other modes such as SIMV or used alone for a spontaneously breathing patient. Cont…

46. The patient ’ s effort determines the rate , inspiratory flow, and tidal volume . In PSV mode, the inspired tidal volume and respiratory rate must be monitored closely to detect changes in lung compliance. It is a mode used primarily for weaning from mechanical ventilation . 5 – 10 cm H20 are generally used, especially during weaning. Cont…

47. During P-A/C the nurse must be familiar with all the ventilator settings: the level of pressure , the set RR, the FiO2, and the level of PEEP The nurse monitors the total RR to evaluate whether the patient is initiating spontaneous breaths and ETV for adequacy of volume. Nurses Responsibility

48. In pressure controlled ventilation the breathing gas flows under constant pressure into the lungs during the selected inspiratory time . The flow is highest at the beginning of inspiration ( i.e when the volume is lowest in the lungs). As the pressure is constant the flow is initially high and then decreases with increasing filling of the lungs. (iv) PCV(Pressure Controlled Ventilation)

49. 1.reduction of peak pressure and therefore the lower risk of barotrauma and tracheal injury . 2.effective ventilation. 3.Improve gas exchange 4. PCV has traditionally been preferred for patients with neuromuscular disease  . Advantages of PCV

50. Careful attention must be given to the TV to prevent unplanned hyperventilation and hypoventilation. Sedation and the use of neuromuscular blocking agents are frequently indicated, because any patient – ventilator asynchrony usually results in profound drops in the SaO2 . Nurses Responsibilities

51. 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. (v) PC-IR Ventilation

52. As expiratory time is decreased, one must monitor for the development of hyperinflation or auto-PEEP. Regional alveolar over distension 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. Nurses Responsibilities

53. Volume Controlled Ventilation: (i) Assist/Controlled Ventilation (ii) Intermittent Mandatory Ventilation (IMV) (iii) Synchronized Intermittent Mandatory Ventilation (SIMV) (2) Volume Cycled Ventilation

54. The ventilator provides the patient with a pre-set tidal volume at a pre-set rate. The patient may initiate a breath on his own , but the ventilator assists by delivering a specified tidal volume to the patient . Client can breathe at a higher rate than the preset number of breaths/minute (i) Assist/Controlled Ventilation

55. The total respiratory rate is determined by the number of spontaneous inspiration initiated by the patient plus the number of breaths set on the ventilator . If the patient wishes to breathe faster, he or she can trigger the ventilator and receive a full-volume breath . Often used as initial mode of ventilation When the patient is too weak to perform the work of breathing ( e.g. when emerging from anesthesia) Cont..

56. The preset RR ensures that the patient receives adequate ventilation, regardless of spontaneous efforts. The patient can breath faster than the preset rate but not slower. Cont…

57. Respiratory alkalosis may develop if the patient has a tendency to hyperventilate because of anxiety , pain or neurological factors . Patient may rely on the ventilator and not attempt to initiate spontaneous breathing if ventilatory demands are met. Disadvantages

58. Total RR, to determine whether the patient is initiating spontaneous breaths. PIP , to determine whether it is increasing( indicating a change in compliance or resistance). Patient’s sense of comfort and synchronization with the ventilator and acid base status. Nurses Responsibilities

59. A mode of mechanical ventilation in which the patient is allowed to breath independently except during certain prescribed intervals, when a ventilator delivers a breath either under positive pressure or in a measured volume . This mode is not use mostly in clinical practice due to many new tech. Modes. (ii) Intermittent Mandatory Ventilation (IMV)

60. The SIMV mode of ventilation delivers a set number of breaths of a set TV, and between these mandatory breaths the patient may initiate spontaneous breaths . If the patient initiates a breath near the time a mandatory breath is due, the delivery of the mandatory breath is synchronized with the patient’s spontaneous effort to prevent patient ventilator dyssynchrony . (iii) Synchronized Intermittent Ventilation (SIMV)

61. SIMV is indicated when it is desirable to allow patients to breath at their own RR and thus assist in maintaining a normal PaCo2,or when hyperventilation has occurred in the A/C mode. SIMV mode helps to prevent respiratory muscle weakness associated with mechanical ventilation. Self regulates the rate and volume of spontaneous breath It is used as a mode for weaning Cont…

62. In between the ventilator-delivered breaths , the patient is able to breath spontaneously at his own tidal volume and rate with no assistance from the ventilator . Ventilators breaths are synchronized with the patient spontaneous breath. Cont…

63. Monitor RR to determine whether the patient is initiating spontaneous breaths, and the patients ability to manage the WOB. Assess PIP, patient’s sense of comfort and synchronization with the ventilator and acid base status . If the total RR increases, the TV of the spontaneous breaths is assessed for adequacy. A rising total RR may indicate that the patient is beginning to fatigue, resulting in a more shallow and rapid respiratory pattern and that may lead to atelectasis. Nurses Responsibilities

64. “Ventilator Alarms defined as a Voice or sound to alert Nurse/Doctor and caused by any abnormal value of either in client or in Ventilator.” These Alarms have 4 main Types as below… (i)Pressure alarms (ii)Volume alarms (iii)Apnea alarms Ventilator Alarms

65. They are triggered when there is increased airway resistance or decreased lung compliance. Low pressure alarms and high pressure alarms (i) Pressure Alarms

66. Volume alarms are valuable for ensuring adequate alveolar ventilation, particularly in the patient receiving a pressure mode of ventilation (ii) Volume Alarms

67. This alarm is very important when the patient is on a spontaneous breathing mode such as PS or CPAP , and no mandatory breaths are set. (iii) Apnea Alarms

68. 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 Alarm Causes

69. 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 Complications

70. An alarm should never be silenced until the cause has been investigated and corrected. If the source of the alarm cannot be determined , disconnect the client from the ventilator and use a hand-held resuscitation bag for manual ventilation with 100% oxygen until the problem can be resolved REMEMBER TWO RULES…..

71. I Airway Complications II Mechanical complications, III Physiological Complications, IV Artificial Airway Complications Complications of Mechanical Ventilation

72. Aspiration Decreased clearance of secretions Nosocomial or ventilator-acquired pneumonia (VAP) (i) Airway Complications

73. Hypoventilation with atelectasis with respiratory acidosis or hypoxemia. Hyperventilation with hypocapnia and respiratory alkalosis Barotrauma - Closed pneumothorax, - Tension pneumothorax , - Subcutaneous emphysema . Alarm “ turned off ” Failure of alarms or ventilator Inadequate nebulization or humidification Overheated inspired air, resulting in hyperthermia (ii) Mechanical complications

74. Fluid overload with humidified air and sodium chloride ( NaCl ) retention Depressed cardiac function and hypotension Stress ulcers Paralytic ileus Gastric distension Starvation Dyssynchronous breathing pattern (iii) Physiological Complications

75. (A) In Endotracheal Tube : Tube kinked or plugged Tracheal stenosis or tracheomalacia Main stem intubation with contralateral ( located on or affecting the opposite side of the lung ) lung atelectasis Cuff failure Sinusitis Otitis media Laryngeal edema ( iV ) Artificial Airway Complications

76. (B) In Tracheostomy Tube : Acute hemorrhage at the site Air embolism Aspiration Tracheal stenosis Failure of the tracheostomy cuff Laryngeal nerve damage Obstruction of tracheostomy tube Pneumothorax Subcutaneous and mediastina emphysema Swallowing dysfunction Tracheoesophageal fistula Infection Accidental decannulation with loss of airway Cont…

77. CVS: Increased intrathoracic pressure Reduced CO2 Pulmonary: Barotrauma (trauma r/t pressure) Pneumothorax Subcutaneous emphysema Complication of Mechanical Ventilation According to Systems

78. Alveolar hypoventilation Cuff leak Ventilator settings Secretions Atelectasis Cont…

79. Alveolar hyperventilation Due to hypoxemia, fear, pain, anxiety → alkalosis RX: sedate, analgesia, communication, correct hypoxemia Due to inappropriate ventilator settings high tidal volume High rate Pulmonary Infection Cont…

80. Neurological complications: Positive pressure ventilation → increased intrathoracic pressure interferes with venous drainage; increased ICP GI: Stress ulcers and GI bleeds; Rx with H 2 receptor blockers Gastric and bowel dilation Cont…

81. Musculoskeletal: Muscle atrophy r/t immobilization Mobilize ROM Psychologic: Stress Communication very important Sedate, explain, family visits, pain management Facilitate expression of needs Cont…

82. Trouble Shooting the Vent Common problems High peak pressures Patient with COPD Ventilator synchrony ARDS

83. 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

84. Cont … High peak pressure differential: 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

85. If you have a patient with history of COPD/asthma with worsening oxygen saturation and increasing hypercapnia differential includes: Given the nature of the disease process, patients have difficultly with expiration (blowing off all the tidal volume) Must be concern with breath stacking or auto- PEEP Management options include: Decrease respiratory rate Decrease tidal volume Adjust flow rate for quicker inspiratory rate Increase sedation Adjust I:E ratio Cont …

86. Cont … 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

87. Cont … If you are concern for acute respiratory distress syndrome (ARDS) Correlate clinically with HPI and 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

88. Weaning is the process of withdrawing mechanical ventilator support and transferring the work of breathing from the ventilator to the patient . It is done only when patient is free from the cause to be kept on mechanical ventilation. “Weaning success is defined as effective spontaneous breathing without any mechanical ventilation for 24 hours or more.” “The process of going OFF from ventilator dependence to spontaneous breathing” Definition of Weaning

89. 3 stages……… pt gradually weaned from --- From Ventilator From Tube From 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 Cont …

90. Tidal volume be above a given threshold (greater than 5 ml/kg), Respiratory frequency be below a given count (less than 30 breaths/min), Oxygen partial pressure be above a given threshold (PaO2 greater than 60mm Hg) and FIO2 <40% Vital capacity 10 to 15 ml/kg. Criteria of Weaning

91. When the above ventilator capacity is adequate…Then CHECK Baseline Measurements like following… Vital Capacity Insp . Force Resp Rate Resting TV Minute Ventilation ABG levels FiO2 Cont …

92. 1) T-piece trial , 2) Continuous Positive Airway Pressure ( CPAP) weaning, 3) Synchronized Intermittent Mandatory Ventilation (SIMV ) weaning , 4) Pressure Support Ventilation (PSV) weaning 5) Continuous Positive Airway Pressure (CPAP) Methods of Weaning

93. It consists of removing the patient from the ventilator and having him / her breathe spontaneously on a T-piece 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 of f the ventilator. 1) T-piece trial

94. for signs & Symptoms of…. Hypoxia, increasing fatigue , Tachy cardia - Ischemic ECG changes Restlessness RR > 35/min Use of accessory muscles for breathing Paradoxical chest movement When on T-piece – observe

95. If tolerating T –piece trial……….ABG – 20mts after spont . breathing at a constant FiO2 ( Alveolar-Arterial equalization occur15-20mins ) If ABG↓ — hypoxia---→ 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 Cont …

96. 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. In pt’s who – satisfies all criteria for weaning but cannot have spontaneous breathing for long time. 2) Synchronized Intermittent Ventilation (SIMV)

97. Respiratory Rate Minute Volume Spont . / Machine Breaths FiO2 ABG levels No deterioration on parameters--- adequate TV, vent resp gradually decreased-- then weaning is complete SIMV for weaning--- observe the following

98. 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 3) Continuous Positive Airway Pressure (CPAP)

99. 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 respirator y rate of less than 25 breaths/minute. PSV weaning is indicated for :- - Difficult to wean patients - Small spontaneous tidal volume. 4) Pressure Support Ventilation (PSV)

100. 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 Weaning from T-Tube/ET..

101. Diaphoresis Dyspnea & Labored respirator y 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. Tidal volume ≤5 mL/kg, Sustained minute ventilation <200 mL/kg/minute Signs of Weaning Intolerance

102. Increase or decrease in blood pressure of > 20 mm Hg Systolic blood pressure >180 mm Hg or <90 mm Hg Increase in respirator y rate of > 10 above baseline or > 30 Sustained respirator y rate greater than 35 breaths/minute SaO2 < 90%, PaO2 < 60 mmHg, decrease in PH of < 7.35.Increase in PaCO2 Cont …

103. O2 therapy ABG evaluation Pulse oxymetry Bronchodilator therapy Chest physio . Adequate Nutrition, hydration, humidification , Incentive spirometry Successful Weaning is Supplemented by…

104. Pt successfully weaned---- and has adequate respiratory function – weaned from O2 FIO2 is gradually reduced until SPO2 is in range of 80-100 mmHg while breathing in Room air If R air SPO2 less than 70 supplementary O2 recommended Weaning from O2..

105. Ensure that extubation criteria are met . Decanulate or extubat Documentation Role Of Nurse after Weaning

106. PHYSIOLOGICAL NEEDS:  comfort  activity  nutrition  elimination of wastes Patients are often not able to fulfill these needs by themselves , nursing function is then for example seeing to comfort, determining intake and output together with blood chemistry to assess adequacy of intravenous nutrition, and so on. NURSING CARE OF CLIENT WITH VENTILATOR

107. SAFETY NEEDS: Threat of injury by person or machines Medication must be checked. Machines must be in best working condition. NEED TO BELONG: Security , means of communication Staff must communicate with the patient and patient must be allowed to respond. Patients need constant reassurance . Cont …

108. NEED FOR RECOGNITION: Esteem , dignity, respect Patients must be treated with respect and addressed correctly. NEED TO CREATE: Expression of self, need to contribute Patients must be involved in the choice and implementation of their treatment. Cont …

109. NEED TO KNOW AND UNDERSTAND: Need for knowledge and comprehension An explanation of diagnosis and treatment on the patient’s level . SELF ACTUALIZATION: Order , truth, privacy Patients should have as much privacy as possible — pull screens or close doors. The patient has the right to be told the truth. Cont …

110. Ineffective breathing pattern Potential for pulmonary infection Impaired water and fluid regulation Oral hygiene Potential altered nutritional status: less than body requirement related to NPO status Potential for complications related to immobility NURSING DIAGNOSIS

111. Knowledge deficit related to intubation and mechanical ventilation Elimination care Promoting coping ability Preventing trauma and infections Promoting rest and sleep Safety and security needs. Cont …

112. 1.LINK“ http:// www.nhlbi.nih.gov /health/healthtopics/topi cs /VENT /” 2 .LINK http://www.mmcwm.com/BiPAP 3 .LINK : “wwwappskc.lonestar.edu/programs/modes.ppt ” 4. WEBPAGE : WWW.WIKIPEDIA.COM & WWW. ENCYCLOPEDIA.COM , TOPIC OF MECHANICAL VENTILATOR & THEIR MODES References

113. Thank You.!