MECHANICAL VENTILATOR BY MR.GOPAL M.SC NURSING.pptx

MR.GOPAL
VICE PRINCIPAL
MDBCON
GUJARAT

1. MECHANICAL VENTILATOR MR.GOPAL.R M.Sc.NURSING ASSOCIATE PROFESSOR MEDICAL SURGICAL NURSING MDBCON, MEHSANA

2. MECHANICAL VENTILATOR Mechanical ventilator is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air in and out of the lungs, with the main goal of helping the delivery of oxygen and removal of carbon dioxide Rajendragopal

3. PURPOSES To deliver high concentrations of oxygen into the lungs To maintain or improve ventilation, & tissue oxygenation. To decrease the work of breathing & improve patient’s comfort To eliminate carbon dioxide Rajendragopal

4. INDICATION Acute respiratory failure due to : Mechanical failure : I ncludes neuromuscular diseases as Myasthenia Gravis, Guillain-Barré Syndrome, and Poliomyelitis (failure of the normal respiratory neuromuscular system) Musculoskeletal abnormalities , such as chest wall trauma (flail chest) Infectious diseases of the lung such as pneumonia, tuberculosis. Rajendragopal

5. Abnormalities of pulmonary gas exchange as in : Obstructive lung disease such as asthma, chronic bronchitis or emphysema, COPD. Other Conditions such as pulmonary edema, atelectasis, pulmonary fibrosis, ARDS, Apnea with respiratory arrest, increased work of breathing as evidenced by significant tachypnea, retractions, Hypotension including sepsis, shock, congestive heart failure Rajendragopal

6. Patients who has received general anesthesia as well as post cardiac arrest patients often require ventilatory support until they have recovered from the effects of the anesthesia or the insult of an arrest. Neurological diseases such as muscular dystrophy and amyotrophic lateral sclerosis Rajendragopal

7.   PARAMETERS   VENTILATION INDICATED NORMAL RANGE 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 ) > 35 / <10   < 5   < 15   <-20 16-24   5-7   65-75   75-100 B- Arterial blood Gases PH PaO 2 (mmHg ) PaCO 2 (mmHg )     < 7.25 < 60 > 50     7.35-7.45 75-100 35-45   Rajendragopal

8. TYPES OF VENTILATION POSITIVE PRESSURE VENTILATION NEGATIVE PRESSURE VENTILATION

9. POSITIVE PRESSURE VENTILATION Positive airway pressure ventilators that use positive pressure to force gas or air into a patient's lungs. Breathing can be triggered by either the patient or the machine. The constant flow permits the patient to easily take spontaneous breaths, making these ventilators a simple, reliable mechanical design. Rajendragopal

10. NEGATIVE PRESSURE VENTILATION The air is withdrawn mechanically to produce a vacuum inside the lungs, thus creating negative pressure. This negative pressure leads to expansion of the chest, which causes a decrease in intrapulmonary pressure, and increases flow of atmospheric air into the lungs . Rajendragopal

11. MODE OF VENTILATOR 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. Volume mode Pressure mode Rajendragopal

12. CLASSIFICATIONS OF MODES VOLUME VENTILATOR MODE PRESSURE VENTILATOR MODE VOLUME CONTROL MODE (VC) PRESSURE CONTROL VENTILATOR (PCV) ASSIST CONTROL MODE (AC) PRESSURE SUPPORT VENTILATOR (PSV) CONTINOUS MANDATORY VENTILATOR PRESSURE CONTROL INVERSE RATIO VENTILATOR (PC-IRV) PRESSURE REGLATED VOLUME CONTROL (PRVC) POSITIVE END EXPIRATORY PRESSURE (PEEP) SYNCHRONIZED INTERMITTENT MANDATORY VENTILATOR (SIMV) CONTINOUS POSITIVE AIRWAY PRESSURE (CPAP) Rajendragopal

13. VOLUME MODE Volume is constant and pressure will vary with patient’s lung compliance. Type of breath : Each breath delivers a mechanical tidal volume Sedation and neuromuscular blocking agent needed . COMPLICATION PEAK airway pressure increases leads to Baro trauma Rajendragopal

14. TYPES OF VOLUME MODE ASSIST-CONTROL (A/C) 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. ADVANTAGES: Reduced work of breathing compared to spontaneous breathing DISADVANTAGES: Potential adverse hemodynamic effects, may lead to inappropriate hyperventilation Rajendragopal

15. PRVC Pressure Regulated Volume Control (PRVC) is a controlled ventilation mode that combines the advantages of volume-controlled and pressure-controlled ventilation.  In PRVC mode, a ventilator attempts to deliver a preset tidal volume at the lowest possible airway pressure.  The mode can also automatically adjust to changes in lung compliance and airway resistance on a breath-by-breath basis. For example, if a patient's lung compliance decreases or airway resistance increases, the system flow and pressure increase.  Rajendragopal

16. SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) In between the ventilator-delivered breaths, the patient is able to breathe spontaneously at his own tidal volume and rate with no assistance from the ventilator Ventilators breaths are synchronized with the patient spontaneous breathe. ( no fighting) Used to wean the patient from the mechanical ventilator. Weaning is accomplished by gradually lowering the set rate and allowing the patient to assume more work DISADVANTAGES Increased work of breathing compared to AC Rajendragopal

17. PRESSURE MODE Pressure is constant and volume will vary with patient’s lung compliance Each breath is delivered at a set volume with a variable flow rate and an absolute pressure limit. The ventilators delivers this pre-set volume at the lowest required peak pressure and adjust with each breath. DISADVANTAGES Low lung compliance and high airway resistances- tidal volume drops and drop in minute ventilation and Paco2 accumulation and respiratory acidosis. Rajendragopal

18. TYPES Pressure-controlled ventilation (PCV) Pressure-support ventilation (PSV) Continuous positive airway pressure (CPAP) Positive end expiratory pressure (PEEP) Noninvasive bi-level positive airway pressure ventilation (Bi-PAP ) Rajendragopal

19. PRESSURE CONTROL VENTILATION (PCV) The PCV mode is used If compliance is decreased and the risk of barotrauma is high. It is used when the patient has persistent oxygenation problems despite a high FiO2 and high levels of PEEP. The inspiratory pressure level, respiratory rate, and inspiratory–expiratory (I:E) ratio must be selected. Tidal volume varies with compliance and airway resistance and must be closely monitored. Sedation and the use of neuromuscular blocking agents are frequently indicated, because any patient–ventilator asynchrony usually results in profound drops in the SaO2. Rajendragopal

20. Risk factors 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 increase plateau pressures that can cause barotrauma & Severe ARDS . Rajendragopal

21. PRESSURE SUPPORT VENTILATION 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. The patient’s effort determines the rate, inspiratory flow, and tidal volume. It is a mode used primarily for weaning from mechanical ventilation. Rajendragopal

22. Risk factors In PSV mode, the inspired tidal volume and respiratory rate must be monitored closely to detect changes in lung compliance. Rajendragopal

23. POSITIVE END EXPIRATORY PRESSURE (PEEP) Positive pressure applied at the end of expiration during mandatory \ ventilator breath Rajendragopal

24. PURPOSES OF CPAP AND PEEP Prevent atelactasis or collapse of alveoli Treat atelactasis or collapse of alveoli edema (pressure help expulsion of fluids from alveoli) Improve gas exchange & oxygenation Treat hypoxemia refractory to oxygen therapy.(prevent oxygen toxicity) Treat pulmonary Rajendragopal

25. NON-INVASIVE BILATERAL POSITIVEAIRWAY PRESSURE VENTILATION (BI-PAP ) Bi-PAP 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). Rajendragopal

26. C OMMON VENTILATOR SETTINGS PARAMETERS/ CONTROLS Fraction of inspired oxygen (FIO2) Tidal Volume (VT) Peak Flow/ Flow Rate Plateau flow rate Respiratory Rate/ Breath Rate / Frequency ( F) Minute Volume (VE) I:E Ratio (Inspiration to Expiration Ratio ) Rajendragopal

27. FRACTION OF INSPIRED OXYGEN (FIO2 ) Initially a patient is placed on a high level of FIO2 (60% or higher). Subsequent changes in FIO2 are based on ABGs and the SaO2. In adult patients the initial FiO2 may be set at 100%. An FiO2 of 100% for an extended period of time can be dangerous ( oxygen toxicity) but it can protect against hypoxemia For infants, and especially in premature infants, high levels of FiO2 (>60%) should be avoided . Rajendragopal

28. TIDAL VOLUME The volume of air delivered to a patient during a ventilator breath. The amount of air inspired and expired with each breath. Usual volume selected is between 5 to 15 ml/ kg body weight) The large tidal volumes may lead to ( volutrauma ) aggravate the damage inflicted on the lungs. For this reason, lower tidal volume targets (6 to 8 mL/kg) are now recommended. Rajendragopal

29. PEAK FLOW/ FLOW RATE Peak inspiratory pressure (PIP) is the highest pressure applied to the lungs during inhalation and should be kept below 35 cmH2O . T oo much pressure can cause harm to the lungs. Rajendragopal

30. PLATEAU PRESSURE Rajendragopal

31. RESPIRATORY RATE/BREATH RATE / FREQUENCY The number of breaths the ventilator will deliver/minute ( 16-24 b/m). Total respiratory rate equals patient rate plus ventilator rate. The nurse double-checks the functioning of the ventilator by observing the patient’s respiratory rate . Rajendragopal

32. MINUTE VOLUME (VE ) Minute ventilation (VE) is the total volume of air entering the lungs in a minute. The average minute ventilation is 6 litres per minute. Minute ventilation = breathing rate × tidal volume. Rajendragopal

33. I:E Normal inspiratory to expiratory ratios (I:E) on spontaneously breathing patients are usually around 1:3 to 1:5. Meaning, the ratio of time in expiration is 3 to 5 times longer than the ratio of time in inspiration Rajendragopal

34. PEEP Positive end-expiratory pressure (PEEP) keeps the airways and small lung spaces open to allow for adequate oxygenation when a person cannot breathe on their own. Rajendragopal

35. VENTILATOR CHART MODE Vt RR Mvt PEEP FIO 2 Ppeak P plat I:E SPO 2 BP VC 489 ------ 500 18 ----- 18 8.8 5 100 % 30 20 1:2 98% 120/80 PCV 458 18 ----- 18 8.2 5 100% 35/35 25/25 1:2 99% 120/80 SIMV/ CPAP 450 16 7.2 5 60% 28 18 1:2 97% 120/80 Rajendragopal

36. COMPLICATIONS OF MECHANICAL VENTILATION : Airway Complications, Mechanical complications, Physiological Complications, Artificial Airway Complications Rajendragopal

37. AIRWAY COMPLICATION Aspiration Decreased clearance of secretions Nosocomial or ventilator-acquired Pneumonia Rajendragopal

38. MECHANICAL COMPLICATION Hypoventilation with atelectasis with respiratory acidosis or hypoxemia. Hyperventilation with hypocapnia and respiratory alkalosis Barotrauma a- Closed pneumothorax, b- Tension pneumothorax, c- Subcutaneous emphysema. Alarm “turned off” Failure of alarms or ventilator Inadequate nebulization or humidification Overheated inspired air, resulting in hyperthermia Rajendragopal

39. PHYSIOLOGICAL COMPLICATION 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 Rajendragopal

40. ARTIFICIAL AIRWAY COMPLICATIONS A- Complications related to Endotracheal Tube: Tube kinked or plugged Cuff failure Sinusitis Otitis media Laryngeal edema Rajendragopal

41. B- Complications related to 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 mediastinal emphysema Swallowing dysfunction Tracheoesophageal fistula Infection Accidental decannulation with loss of airway Rajendragopal

42. Rajendragopal